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Hearing Transcript on Substance Abuse/Comorbid Disorders: Comprehensive Solutions to a Complex Problem.
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SUBSTANCE ABUSE/COMORBID DISORDERS: COMPREHENSIVE SOLUTIONS TO A COMPLEX PROBLEM
HEARING BEFORE THE SUBCOMMITTEE ON HEALTH OF THE COMMITTEE ON VETERANS' AFFAIRS U.S. HOUSE OF REPRESENTATIVES ONE HUNDRED TENTH CONGRESS SECOND SESSION MARCH 11, 2008 SERIAL No. 110-75 Printed for the use of the Committee on Veterans' Affairs
U.S. GOVERNMENT PRINTING OFFICE For sale by the Superintendent of Documents, U.S. Government Printing Office
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CORRINE BROWN, Florida |
STEVE BUYER, Indiana, Ranking |
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Malcom A. Shorter, Staff Director SUBCOMMITTEE ON HEALTH
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public hearing records of the Committee on Veterans' Affairs are also published in electronic form. The printed hearing record remains the official version. Because electronic submissions are used to prepare both printed and electronic versions of the hearing record, the process of converting between various electronic formats may introduce unintentional errors or omissions. Such occurrences are inherent in the current publication process and should diminish as the process is further refined. |
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C O N T E N T S
March 11, 2008
Substance Abuse/Comorbid Disorders: Comprehensive Solutions to a Complex Problem
OPENING STATEMENTS
Chairman Michael Michaud
Prepared statement of Chairman Michaud
Hon. Phil Hare
Hon. Shelley Berkley, prepared statement of
Hon. John T. Salazar, prepared statement of
WITNESSES
U.S. Department of Veterans Affairs, Antonette Zeiss, Ph.D., Deputy Chief Consultant, Office of Mental Health Services, Veterans Health Administration
Prepared statement of Dr. Zeiss
Disabled American Veterans, Joy J. Ilem, Assistant National Legislative Director
Prepared statement of Ms. Ilem
Iraq and Afghanistan Veterans of America, Todd Bowers, Director of Government Affairs
Prepared statement of Mr. Bowers
McCormick, Richard A., Ph.D., Senior Scholar, Center for Health Care Policy and Research, Case Western Reserve University, Cleveland, OH
Prepared statement of Dr. McCormick
NAADAC, the Association for Addiction Professionals, Patricia M. Greer, President
Prepared statement of Ms. Greer
Vietnam Veterans of America, Thomas J. Berger, Ph.D., Chair, National PTSD and Substance Abuse Committee
Prepared statement of Dr. Berger
SUBMISSIONS FOR THE RECORD
American Legion, Joseph L. Wilson, Deputy Director, Veterans Affairs and Rehabilitation Commission, statement
Miller, Hon. Jeff, Ranking Republican Member, and a Representative in Congress from the State of Florida, statement
SUBSTANCE ABUSE/COMORBID DISORDERS: COMPREHENSIVE SOLUTIONS TO A COMPLEX PROBLEM
Tuesday, March 11, 2008
U. S. House of Representatives,
Subcommittee on Health,
Committee on Veterans' Affairs,
Washington, DC.
The Subcommittee met, pursuant to notice, at 10:00 a.m., in Room 334, Cannon House Office Building, Hon. Michael H. Michaud [Chairman of the Subcommittee] presiding.
Present: Representatives Michaud, Berkley, Hare, and Salazar.
OPENING STATEMENT OF CHAIRMAN MICHAUD
Mr. MICHAUD. I call the Subcommittee to order, and ask our first group of panelists to please come to the table.
I would like to welcome everyone to our Subcommittee hearing today. We are here today to talk about treatment for substance abuse and comorbid conditions within the U.S. Department of Veterans Affairs (VA).
Substance use disorders (SUDs) are among the most common diagnoses made by the Veterans Health Administration (VHA). According to the 2007 National Survey on Drug Use and Health, 7.1 percent of veterans met the criteria in the past year for a substance use disorder. And 1.5 percent of veterans had a co-occurring substance use disorder.
Of the approximately 300,000 veterans from Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) who have accessed VA healthcare, nearly 50,000 have been diagnosed with substance use disorder. Additionally, more than 70 percent of homeless veterans suffer from alcohol and drug abuse problems.
Over the past several years, Congress has increased funding for substance use treatment programs within the Department of Veterans Affairs to $428 million in fiscal year 2008. I believe that continuing adequate funding is imperative for the health and well being of our veterans and their families.
Substance use frequently co-occurs with other mental health conditions. VA needs to continue to dedicate itself to providing services that can address both substance use and other mental health conditions such as post traumatic stress disorder (PTSD) simultaneously.
I also was pleased to learn that Dr. Kussman, VA's Under Secretary for Health, recently released a directive on the management of substance use disorders. This directive states that, among other things, VA facilities must not deny care to any enrolled veteran because they are using substances. And that all VA medical facilities must provide services to meet the needs of veterans with substance use disorders and PTSD.
I think that this is a step in the right direction. I commend VA for its proactive leadership on this.
Last week, Mr. Miller and I introduced the "Veterans Substance Use Disorder Prevention and Treatment Act of 2008." The Subcommittee realizes that substance use and comorbid conditions are complex issues. But we also recognize that it is important and that this deserves serious thought and consideration.
I look forward to hearing from our panels today about the ways that the VA can effectively address these critical issues.
[The statement of Chairman Michaud appears in the Appendix.]
Mr. MICHAUD. And now I would like to recognize Mr. Hare for an opening statement.
OPENING STATEMENT OF HON. PHIL HARE
Mr. HARE. I will be very brief. Thank you, Mr. Chairman. I want to thank you for holding this hearing and the continuance of hearings that you have organized about veterans mental healthcare.
Substance use disorder and its comorbidity with post traumatic stress disorder are clearly a significant health issue among our returning veterans. And while it is crucial that we must understand what needs our veterans have, I believe that we must act quickly to ensure that the VA is providing the necessary services uniformly and across the Nation.
And, again, Mr. Chairman, I thank you very much for this series of hearings. You do a wonderful job as Chairman of this Subcommittee, and I hope to have an informative hearing this morning. Thank you so much.
Mr. MICHAUD. Thank you very much, Mr. Hare, for your leadership on veterans' issues as well.
Our first panel is comprised of Patricia Greer, who is the President of NAADAC, the Association for Addiction Professionals; and Dr. Richard McCormick, who is a Senior Scholar from the Center for Health Care Policy and Research at Case Western Reserve University in Cleveland, Ohio.
I would like to welcome both of you here this morning. And look forward to hearing your testimony. And we will start with Ms. Greer.
STATEMENTS OF PATRICIA M. GREER, PRESIDENT, NAADAC, THE ASSOCIATION FOR ADDICTION PROFESSIONALS; AND RICHARD A. MCCORMICK, PH.D., SENIOR SCHOLAR, CENTER FOR HEALTH CARE POLICY AND RESEARCH, CASE WESTERN RESERVE UNIVERSITY, CLEVELAND, OH
STATEMENT OF PATRICIA M. GREER
Ms. GREER. Thank you, Mr. Chairman and Members of this Subcommittee, for holding today's hearings.
The multiple challenges to our healthcare system to effectively treat co-occurring substance use disorders are significant. But experience has proven that there are practical steps, which will improve outcomes for clients and their families.
I represent NAADAC, the Association for Addiction Professionals. We are the national professional association for addiction-focused health professionals and educators. NAADAC has 10,000 members across the United States and partner organizations in 46 States, two territories, and several foreign countries.
I would like to take a minute to note the scope of the problem of substance use disorders and comorbidity. In 2004, Dr. Richard Suchinsky ranked substance use disorders as third in the list of diagnoses made by the VHA.
However, reflecting a similar treatment gap in civilian society, substance use disorders remain under diagnosed and under treated in the VHA. In total, it is estimated that 1.8 million veterans suffered from a diagnosable substance use disorder in 2002 and 2003.
Substance use disorders often co-occur with other physical and mental health conditions. In the case of mental health conditions like PTSD, depression, or bipolar disorder, substance use disorders may develop from attempts to self-medicate.
Some experts estimate that about 40 percent of the veterans who have served in Iraq or Afghanistan will experience mental health problems. And of that number, approximately 60 percent will have a substance use disorder. National Guard forces report even higher rates of psychological distress than do the regular forces. And the stigma against addiction and treatment, discourages many people from even seeking help.
The Department of Veterans Affairs and Congress should be commended for having made mental healthcare for veterans a priority over the past several years.
As this hearing's title suggests, co-occurring addiction and mental disorders are best treated comprehensively. Treatment for substance use disorders is most effective when delivered by trained healthcare professionals with either a certification or license in addiction-specific care. Licensure and certification ensures that the practitioner has both the education and the clinical experience in evidence-based practices to provide the best possible care.
The commitment by the VHA to prioritize treatment for co-occurring addiction and mental illness must include a commitment to expand and train its addictions-focused workforce. Reports that the addiction-focused VHA workforce has declined by almost half in the past decade are particularly disturbing.
Simply stated, comprehensive care for co-occurring disorders requires professionals with knowledge of both the areas of addiction and mental health trauma.
Additionally, several steps may be taken to enhance the comprehensiveness of care.
First, early screening and intervention leads to more successful results. Of the veterans in the VHA system with diagnosable substance use disorders, only 19 percent received specialized addiction treatment. Primary care health practitioners must be trained in identifying substance use disorders and their co-occurring mental health conditions. And qualified addiction professionals should be on-call to provide interventions when needed.
Second, we believe that the VA should be accountable and transparent in cases where they do deny treatment to a veteran claiming to have combat-related symptoms or substance use disorders and report that information publically.
Third, culturally competent care reflecting familiarity with military culture is essential for effective treatment. Fourth, the current conflicts require a new emphasis on gender-specific treatment strategies. Servicewomen are closer to combat than ever before. Female veterans are more vulnerable to PTSD.
The VHA should invest in studying gender-specific treatment and counseling strategies.
Fifth, with the high rates of Reservists and National Guard forces in combat and extended tours of duty, families are under extreme stress. Post-deployment reintegration is often surprisingly difficult. Family inclusion in treatment programs are recommended whenever possible.
Sixth, access to treatment should be as convenient and client-friendly as possible. Compared with the civilian system, both public and private, substance use disorder-specific care in the VA takes place in hospitals that are densely populated and less geographically dispersed than civilian treatment sites. This problem is particularly pronounced for veterans in rural areas.
We encourage the Department of Veterans Affairs to aggressively pursue partnerships with existing civilian treatment centers. Strategic partnerships that expand the capacity of existing treatment systems in underserved areas would provide veterans and their families with timely care close to home, which is much more successful.
In conclusion, the current conflicts in Iraq and Afghanistan pose many new challenges requiring a comprehensive plan of action.
We would like to commend the Department of Veterans Affairs, this Subcommittee, and other policymakers who have worked to improve veterans' access to healthcare in the past several years.
We look forward to working with other stakeholders to improve the Nation's treatment systems for co-occurring substance use disorders. I thank you for the opportunity to testify today. And I would also like to acknowledge the addictions treatment professionals in the room who are also veterans with us today. And I would be happy to answer any questions.
[The statement of Ms. Greer appears in the Appendix.]
Mr. MICHAUD. Thank you very much. Dr. McCormick?
STATEMENT OF RICHARD A. MCCORMICK, PH.D.
Dr. MCCORMICK. Mr. Chairman, Members of the Subcommittee, I will attempt in my limited remarks today to provide an independent, ground-level assessment of the needs of veterans for substance abuse disorder services and the current capability of VA to provide them.
Let me first share the basis for my assessment. I retired a few years ago after 32 years in VA, where I worked clinically, mostly in substance abuse. Ending my career as the Mental Health Care Line Director for Network 10.
I was Co-chair of the VA National Committee on the Care of Severely Mentally Ill Veterans, the mental health representative to the VA Central Office Task Force overseeing all practice guidelines, and Co-chair of the group drafting the practice guidelines for dually-diagnosed veterans.
After I retired, I had the additional opportunity to personally visit 39 VA facilities. First as a Commissioner on the VA Cares Commission, also as a member of a special Secretary's mental health task force, and then as a consultant on mental health and substance issues at a number of facilities.
The last two years, I personally had the opportunity to visit 23 military bases and Reserve units across the world as a member of the Department of Defense (DoD) Mental Health Task Force.
On these visits, I talked to literally thousands of servicemembers, families, and providers about substance abuse and mental health issues.
I continue to conduct National Institute on Alcohol Abuse and Alcoholism funded research at the university and am involved in two large Department of Defense follow-up studies on the mental health status of National Guard and Reserve members.
First of all, the scope of the problem. The need for comprehensive substance use disorder services is immense and growing. Multiple studies show high rates of problems for returning War on Terror members.
For example, among reservists who are veterans, weeks within their return, across studies looking at confidential surveys, it ranges from the 25 to 35 percent range on average for alcohol problems. When you look at the subset who have frequent deployments and high combat exposure, it goes as high as 52 percent.
This hearing importantly focuses on comorbidities. Substance abuse is a common comorbidity for mental and social problems. The veteran must be able to access good substance abuse services to deal with other conditions as well. For example, most—all PTSD programs require that someone either concurrently or before they enter PTSD treatment deal with the substance abuse problem, which is a common comorbidity for up to one third of those going into treatment.
There is growing concern with suicidality. A recent VA study of over 8,000 veterans in substance abuse treatment found that the year before they entered treatment, 9 percent had—attempted suicide. The year after, 4 percent. The good news is there was a direct relationship to the amount of substance abuse treatment they got and the decrease in suicidal behavior.
What is the—let me just say that VA's priority medical and mental health programs need a state-of-the-art substance abuse program to provide the care they need to provide.
What is the state right now? VA has been a leader in establishing evidence-based guidelines for substance use disorders. We know what works. In the past decade, VA substance abuse care has greatly eroded. Official VA reports document the decline. Much less is being spent on the care. Two hundred million dollars less than was spent in fiscal year 1996.
Some of that might be attributed to increased efficiency were it not for the fact there has also been a drastic decline in the number of unique veterans getting substance abuse care in VA. Nor is this due to lack of need. Three networks actually increased the care they provide, while increasing efficiency.
But the result of this decline across the system, is that there is a vast discrepancy in access of a full—to a full continuum of care across the country.
Small improvements can be noted in the past couple of years with new money. But even still, there are examples of medical centers that take expansion money for one thing and continue to reduce substance abuse services.
There are many dedicated staff who provide care. Most VA programs do focus on the more severe, dependent abusers. But the new veteran often needs a new kind of service. He or she may be at the beginning of a long drop, binge drinking, getting caught driving under the influence (DUI), getting DUIs, starting to destroy family relationships.
In the private sector, you will find examples, many examples, of comprehensive brief intervention initial treatment programs for such patients.
Alarmingly, these are rare in VA. There are certainly examples of bright spots where it is happening. But across the system, they just aren't there.
I could go on providing more details. But let me end with a true story. On a visit to a Reserve unit last year, I was approached by a reservist home from his second deployment. He was changed. He knew it. His sergeant knew it. His wife knew it. He was drinking too much. He wasn't the father or husband he always saw himself being. He had had a tough time in deployment, but he didn't want to talk about that. And he was reluctant even to go get some help with his alcohol problem.
But he did want to do something. I directed him to the nearest VA facility nearest where he lived. It was not one I had visited recently. I hope he found ready, immediate access to services that he needed, before he talked himself out of sticking with it. Then and now, I am not sure he would.
[The statement of Mr. McCormick appears in the Appendix.]
Mr. MICHAUD. Thank you very much, Dr. McCormick.
As you know, one of the issues that is important to me is access to veterans' health care for our veterans, all over the United States, but particularly in rural areas.
What, Dr. McCormick, are some of the challenges in providing substance abuse treatment in rural areas? We heard Ms. Greer mention partnerships are one opportunity. Could you talk about the effectiveness of telephonic- or internet-based treatment for substance use disorders?
Dr. MCCORMICK. Yes, thank you. One of the great strengths of VA, as you know, I am sure Mr. Chairman, is the establishment of community-based outpatient clinics (CBOCs), which are much more accessible, including especially to rural veterans than our medical centers generally.
It is appropriate to have the most intensive substance abuse services at a medical center to a degree. But at every CBOC, every community-based outpatient clinic, in primary care, there needs to be someone who is expert in providing brief interventions to try to immediately impact, especially on those who are misusing rather than fully dependent, before they spend years going down that deep drop.
And that isn't true right now. Even four years after people are coming back—and they need the services right when they come back to stop the drop. And that is true in rural. My own view is that the only way we will ever really attack the rural issue completely is for VA to contract some of that care in local communities.
I myself believe VA can still be the provider of care and payer for care. But especially if it is an intensive outpatient program or even frequent outpatient visits, the reality is that if a veteran—I hear this many times. If a veteran has to drive 100 miles both ways, with the price of gas today, that is not free care. That is real expensive care. It is true in Ohio. I am sure it is true in other rural areas, Florida as well.
So that, yes, I think VA needs to bolster its programs, its intensive programs at the medical center. Make sure every CBOC can really provide immediate care. And I will say that there was a survey done. I was part of the group in 2004, VA's Health Services Research and Development Service (HSR&D) study, a survey of the leaders of primary care and ambulatory care in VA. The number one barrier they saw through their veterans—and they thought 29 percent of them had alcohol problems. The number one problem they had getting them to have short, brief treatment, was lack of resources.
So VA can direct the care, pay for the care, but they will have to contract in some areas to make it truly accessible and useful.
Mr. MICHAUD. What about internet-based treatment? Do you think that is effective?
Dr. MCCORMICK. In terms of—you know, I really feel that the jury is out whether it is better to treat the disorders at the same treatment site or in separate treatment programs.
But I would stress that the most important thing is that good care for mental health conditions and for medical conditions—take for example hepatitis C, you can't really—the effective treatments for hepatitis C requires someone—the need to be alcohol free. Likewise, even TBI, traumatic brain injury, one of the cardinal symptoms is disinhibition, often misuse of alcohol.
And in fact, the current DoD advice for TBI patients is to abstain from alcohol. If somebody has TBI and has an alcohol problem, they need to be able to get those services.
I myself think the jury is out whether they have to be done at the same time. We are still at the point of trying to make sure that every place we should have it, we have a robust, full continuum of care. So at least it can be offered concurrently.
Mr. MICHAUD. Ms. Greer, would you want to answer that question about internet-based treatment?
Ms. GREER. My concern on internet-based treatment is that one of the hallmarks of addiction is disconnection from your family, your friends, and your support network, your natural support network. So I find it difficult to endorse internet-based treatment for addiction disorders.
Mr. MICHAUD. Ms. Greer you recommend that the VHA should provide resources to its current healthcare workforce to become certified or licensed in addiction-specific treatment.
How many VA health professionals are currently certified or licensed? What is the process you have to go through?
Ms. GREER. Well, actually it varies from State to State at this point. All the armed services actually have a process, I believe, for certifying people that are interested in being certified addictions professionals. But it is not consistent nationally.
Mr. MICHAUD. And with, mental health treatment, involvement of the family members is—I feel is extremely important. How do you both, Ms. Greer and Dr. McCormick, envision what that family involvement should look like? Do you feel that the VA currently promotes family involvement in substance use disorder treatment for our veterans?
Dr. MCCORMICK. Let me try that first. That is an excellent question. The reality is that there is less involvement of family actively in VA substance abuse programs than any comparable programs elsewhere in the community.
Partly this is regulatory or at least staff belief about regulations. The reality is, especially for the new War on Terror veteran coming back, when you talk to National Guardsmen when survey—when we do surveys of them, marital problems are where things start to surface first, especially with repeated deployments.
And yet, most VA medical centers don't make marital counseling readily accessible. It is available at Vet Centers. But, again, I would remind everyone that Vet Centers are much less accessible as an entity than our medical centers. And Vet Centers don't really do substance abuse care. So you are talking about trying to separate two things that should be separated, because the family, the wife—we are losing families.
And because of losing families, we are losing veterans and servicemembers, including to suicide. It is the number one factor. You take these three things together: family problems, or relationship problems, or a "dear John" e-mail, alcohol and access to a weapon. That is what you see happening. That is why you see suicide. And that is why you see it so much.
Mr. MICHAUD. Ms. Greer, do you want to add anything to that?
Ms. GREER. I think that informing family members of the role that they play in post-deployment reintegration would be a key step in helping the adjustment to coming home, especially with marital difficulties.
My concern is that speaking to professionals in Fort Hood, I understand their caseloads are in excess of 300, just with returning veterans themselves. And they are not able to handle the family connections that would go with treating the people they serve.
So I don't know how it is nationally. But I know the local providers in Fort Hood are overwhelmed.
Mr. MICHAUD. Thank you. And my last question, Dr. McCormick, since you formerly worked at the VA, we can provide all the resources that we think is needed in this particular area. But my concern is once that we do that, is to make sure that the resources get to the veterans that need it.
I guess my question is how do you see that we as a Committee can make sure that the resources get where they are needed? What type of oversight do you think we need? Is there any report language that we should require the VA to report back?
And the other issue is if we do not—if the veteran does not get the services that they need, what is that actual cost of that—to society as a whole? How much more expensive would it be since they are not getting the services that they need?
Dr. MCCORMICK. Two very important questions. Let me take the first one. You know, when I first came to VA, it was described to me as a series of fiefdoms. It changed somewhat, but not a lot.
On the other hand, one of the things that has happened that is very good in VA, is the establishment of practice guidelines. Now the substance abuse guidelines need to be expanded with modern services on misuse for new veterans. One that is done, my own belief is that a report card needs to be done on each and every medical center, comparing each and every medical center as to which parts of the continuum of care in VA's own evidence practice guidelines are readily available and accessible at that site.
That report card should be used for two things. It ought to be made public, because frankly there are VA administrators at the local level who are recalcitrant about substance abuse services. But the light of day of a report like that gets converts that—and nothing else would get.
Number two, it allows the money that you do give to go to the right places, because the bottom line is—as the Member correctly said earlier, the bottom line is to try to get accessible services across the whole system. So that if a veteran living in Ohio, who has a problem, gets the same access as one who lives in Florida. And the one in Ohio is probably depressed, because all the defeats we have had from Florida teams lately but beyond that.
The second question you asked is also, you know, important—very important as well. And that has—but you have to remind me of it, because I am an old man.
Mr. MICHAUD. Well, first of all, you mentioned having that report card.
Dr. MCCORMICK. Right.
Mr. MICHAUD. Would you be willing to help to put together what that report card should look like? I think all too often what happens is once we pass legislation and it becomes law, that is it. There is really not much follow up.
So I would like to make sure that, number one, that we have a report card that is legitimate and would really help us. And second, we can evaluate exactly what the Veterans Integrated Services Networks (VISNs) and VA are doing. So would you be able to help with the Committee staff?
Dr. MCCORMICK. Yeah. And there are many old VA people like myself who are around to do that. I would be glad to.
I am still trying to remember the second important question.
Mr. MICHAUD. The second question is when you look at taking care of our substance abuse, that has a cost to it.
Dr. MCCORMICK. Thank you.
Mr. MICHAUD. But if we do not put that money up front, then there are other social costs that could be more expensive, including, unfortunately, loss of life because of suicide.
Dr. MCCORMICK. Well, yes. So first of all, there is—there are social costs, obviously, to the family and to the veteran himself. There are also medical costs, because untreated—substance abuse treatment does work, although it is a chronic condition. And the earlier we intervene, the more likely we are to be successful down the road.
The good news is the early interventions are our least expensive. So they save not only the veteran and his family all the psychological and social pain, they actually save money over time if we do them well.
When substance abuse gets to be chronic, as somebody mentioned earlier, you get all kinds of things, including homelessness. Actually the number of patients in our homeless programs is more than 70 percent that have a substance abuse problem.
And also there is a medical cost. Again, as I said earlier, and I just used two examples, I am on—we are doing a very large study on hepatitis C. If you aren't able to address substance abuse, it does really make it impossible to provide some state-of-the-art medical treatments, because alcohol—excessive use of alcohol really keeps you from taking antivirals and many of the drugs that are most effective for that. So there is also a medical cost over time.
Mr. MICHAUD. Thank you. Ms. Greer, did you want to add anything?
Ms. GREER. I just wanted to add, that the Federal Government has studied this issue. I think it was around year 2000, and it indicated that for every dollar we spend on intervention, prevention, early treatment, we save $7 down the road avoiding incarceration, the chronic deterioration by a chronic disease, and all the related societal costs.
Mr. MICHAUD. That is a very good point. It would probably be worthwhile to get an up-to-date cost, since that is eight years old.
Ms. GREER. Well, I am sure they could help us?
Mr. MICHAUD. Yes. Thank you. Mr. Hare?
Mr. HARE. Thank you, Mr. Chairman. Ms. Greer, from your experience, is the treatment offered for SUD or addictions at the VA similar as far as programmatic aspects to those of the public sector?
Ms. GREER. Unfortunately, I can't address that question. I haven't worked within the VA system. I only have secondhand reports.
Mr. HARE. Okay. Dr. McCormick, would you?
Dr. MCCORMICK. They are for—if we are talking about programs for fully dependent patients, they are actually quite similar. The basis of them is really an intensive outpatient program with a residential option.
A couple of things are different. There are few—there is less availability for methadone maintenance, which is actually—has a very heavy evidence base in VA than it is in the private sector. I also do consulting in the private sector.
And the other one that I would, again, underscore, the—one of the huge differences that perhaps is most pertinent to the War on Terror is that VA programs are much less likely, in my personal experience, to offer early, short, brief interventions for people who are just starting down the slope.
Our programs in VA tend, because of the kinds of patients we have treated over the years, to be kind of the end-of-the-line programs. Now when I go around the Nation and you talk to VA substance abuse people, they recognize this. They would like to provide short, brief interventions. They just don't have the time. They are already barely floating.
Mr. HARE. Well, Doctor, let me—you know, I know you worked in the VA system, as you mentioned, for several years and traveled all over the country. And let me first of all thank you for your service. It is a wonderful thing to do. But can you tell—maybe tell me how much of an understanding do you think the VHA professionals have about SUD? There seems to be a lot of stigma surrounding SUD and whether it is, you know, the willpower to stop, rather than a medical condition.
And I guess my other part to that question is do you find this a problem in the VHA facilities? And would you agree with Ms. Greer's assessment that more specialized training for SUD need to be integrated into the VHA? It is a long question. I apologize.
Dr. MCCORMICK. No. Let me start. When you start at the ground up, if you talk to primary care doctors, having people come in for a 15, 20, most 30-minute visit, and as I said before, their own people say 29 percent of them have an alcohol problem. They recognize it is a problem. They recognize they have neither the time nor the training to address it.
So they have to rely on the availability of other resources, particularly in the specialized substance abuse programs, which often are not really accessible for them or don't offer the kind of services their patients needed.
As you go up the line, there are certainly many very enlightened VA clinicians and VA managers regarding the importance of substance abuse treatment. But there are many who are not. And this is one of the reasons that you have the undeniable variation. I mean, there is an order of three variation on the number of—the percentage of patients treated completely who get substance abuse care in the VA by network.
So there is no question that that is a reality that, again, has to be overcome through top-down enforcement of a consistent continuum of care across the system.
Mr. HARE. And lastly, I don't want to run out of time here, Mr. Chairman, but I just want to ask Ms. Greer one question. Just to clarify what the difference is, if any, between substance abuse disorder and an addiction?
Ms. GREER. An addiction?
Mr. HARE. Mm-hmm.
Ms. GREER. You can have a substance abuse disorder that progresses to addiction. You may just have somebody that is in a phase of abusing substances. And that would be a substance abuse disorder. And that would be a warning that there is potential for dependency or addiction.
Mr. HARE. I thank you very much. Thank you, Mr. Chairman.
Mr. HARE. Thank you. Ms. Berkley?
Ms. BERKLEY. I thank you, Mr. Chairman. And thank you for holding this very important hearing.
I would like to be able to submit my opening statement for the record, if I may.
Mr. MICHAUD. Without objection.
Ms. BERKLEY. Thank you.
[The statement of Congresswoman Berkley appears in the Appendix.]
Ms. BERKLEY. Thank you. Thank you both for being here to discuss with us a very important issue and to help educate us. And we always appreciate that.
A constituent of mine, Lance Corporal Justin Bailey returned from Iraq with PTSD. He developed a substance abuse disorder. And I know that they go hand in hand. He checked himself—with his family's insistence, checked himself into the LA VA facility in West Los Angeles. After being given five medications on a self-medication policy, Justin Bailey overdosed and died. His family, obviously, are beside themselves. And can't understand how he went in with a substance abuse problem, and was given more medication unsupervised.
I have introduced the "Mental Health Improvements Act," which aims to improve the treatment and services provided by the Department of Veterans Affairs to veterans with PTSD and substance abuse disorders.
And what the legislation does is it expands substance abuse disorder treatment services at VA medical centers. It establishes national centers of excellence on PTSD and substance abuse disorders. It creates a program for enhanced treatment of substance use disorder and PTSD in veterans. It requires a report on residential mental healthcare facilities in the VA, creates a research program on comorbid PTSD and substance abuse disorders, and it expands assistance of mental health services for families of veterans.
I think it is imperative that we provide adequate mental health services for those who have sacrificed for this Nation and those who continue to serve. Often times these problems don't manifest themselves until quite a while after the service. But it is a serious issue. And we are recognizing it now, where I think in past wars, it existed. And we just chose not to recognize it.
I am hoping that my colleagues, and I know there is only two here, will help cosponsor this and move it along. I think it is important and will help.
But, Ms. Greer, I wanted to ask you. I am not sure. I mean, we are putting a lot of burden on our VA. In addition to the healthcare that our veterans require when they come home, and we will have several hundred thousand if not close to a million veterans from the current action and our resources are scarce. Added to the healthcare issues is also the mental health issues.
And I am not sure—as a matter of fact I am quite convinced that we don't have enough people—doctors in the VA to accommodate the—what we are tasking them with, and will continue to task them with, and expand their task.
Ms. Greer, do you think it would be beneficial to allow civilians to provide care to veterans with substance abuse disorders if they are qualified addiction specialists? Because right now our military people have to go through the VA.
If we don't have enough personnel, and enough doctors, and enough addiction specialists to handle the influx of people that need their services, do you think it would be appropriate to reach out or go beyond the VA and certify addiction specialists that are not in the VA system to help treat these people?
Ms. GREER. Well, absolutely. The establishment of professional standards is part of what our association does. So I can wholeheartedly recommend using certified addiction professionals or licensed addiction professionals, because they have got the training and the specific ability to be meaningful in their interventions with clients.
Ms. BERKLEY. Thank you very much.
Mr. MICHAUD. Thank you. Mr. Salazar? Well once again, Ms. Greer and Dr. McCormick, I want to thank you very much for your enlightening testimony. I appreciate you coming here today.
Dr. MCCORMICK. Thank you.
Ms. GREER. Thank you, Mr. Chairman.
Mr. MICHAUD. I now ask the second panel to come forward. Joy Ilem who represents the Disabled American Veterans (DAV); Doctor Thomas Berger who represents the Vietnam Veterans of America (VVA); and Todd Bowers who represents the Iraq and Afghanistan Veterans of America (IAVA).
And I would like to thank the three of you for coming forward today to give your testimonies. And I would start off with Ms. Ilem.
STATEMENTS OF JOY J. ILEM, ASSISTANT NATIONAL LEGISLATIVE DIRECTOR, DISABLED AMERICAN VETERANS; THOMAS J. BERGER, PH.D., CHAIR, NATIONAL PTSD AND SUBSTANCE ABUSE COMMITTEE, VIETNAM VETERANS OF AMERICA; AND TODD BOWERS, DIRECTOR OF GOVERNMENT AFFAIRS, IRAQ AND AFGHANISTAN VETERANS OF AMERICA
Ms. ILEM. Thank you Mr. Chairman and Members of the Subcommittee.
Thank you for inviting the Disabled American Veterans to testify at this important hearing on substance use and co-existing mental health disorders in the veteran population.
We owe our Nation's disabled veterans access to timely and appropriate care, including specialized treatment programs for those suffering with post-deployment mental health and substance use disorders.
DAV has a growing concern about the reported psychological effects of combat deployments on veterans who have served in Iraq and Afghanistan. There is converging evidence that substance use among other post-deployment mental health problems is a significant problem challenge for many of these veterans. And that the incidence of this problem will likely continue to rise if not properly addressed.
At one facility, VA researchers examined substance abuse and mental health problems in returning Iraq veterans and concluded that increasing attention is being paid to combat stress disorders but that there was insufficient systemic focus on the substance abuse problems in this population.
Access to substance abuse services for the group studied was very low, only 9 percent, compared with access to other mental health services, reported at 41 percent.
In my written statement, I also cite a number of other studies that illustrate the apparent nature and scope of this problem.
Unfortunately, over the past decade, VA substance abuse rehabilitation services have declined and VA has made little progress in restoring them, even in the face of higher demand from the newest generation of combat veterans.
Although it is well known that many mental health conditions, including PTSD, anxiety disorders and depression are frequently associated with substance misuse, VA is not sufficiently focused on restoring these specialized services, including integrated treatment programs to address these co-existing disorders.
We are also concerned about the market increase in geographic variability of access to comprehensive substance abuse services noted across the VA system, as well as reported inconsistencies in offering inpatient detoxification services.
We hope VA will set in place clear policies to ensure that a comprehensive set of substance abuse disorder services are available and consistently provided to all veterans who need them. These services should include screening in all care locations, particularly in primary care; short-term outpatient counseling, including motivational intervention; ongoing aftercare and outpatient counseling; intensive outpatient treatment; residential care for the most severely addicted; detoxification and stabilization services; ongoing aftercare and relapse prevention; self-help groups; and, opiate substitution therapy and other pharmacological treatments, including access to newer drugs to reduce cravings.
While we applaud VA's efforts to save individuals from the misery of chronic addiction, we note that VA has traditionally limited its program focus on those who have seemingly hit rock bottom. Experts agree that early interventions for substance use are more successful when they have not been allowed to become compounded or chronic.
Therefore, we believe access to a robust array of substance abuse disorder services and an expanded focus on prevention and early intervention is not only warranted, but critical to our newest generation of war veterans suffering with post-deployment readjustment issues.
Lack of access to such services could result in sub-optimal rehabilitation for thousands of veterans, including many with comorbid medical and mental health conditions that require concurrent retreatment of their alcohol and/or substance use disorders.
With these views in mind, DAV recommends the Subcommittee advance legislation that assures a full continuum of substance use disorders care for veterans who need it, along with an annual updated to Congress on VA's progress in providing such services.
We also urge authorization of a pilot program, specifically designed to offer web-based options for VA substance use counseling, treatment, and group support targeted at rural veterans.
And finally designated funding for research projects to identify best treatment strategies to collectively address substance use disorders and other comorbid mental health readjustment problems.
Congress and VA must ensure that Federal programs aimed at meeting the unique post-deployment needs of veterans are sufficiently funded and adapted to meet them, while continuing to address the chronic health maintenance needs of previous generations of disabled veterans.
Additionally, Congress should require VA to report on how it is spending the significant new funds that have been added and earmarked for the purpose of meeting post-deployment mental healthcare and physical rehabilitation needs of Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) veterans.
In closing, VA needs to have effective programs in place now aimed at prevention and early intervention, outreach and education, as well as training for veterans and their families to close the current gaps that exist.
We deeply appreciate the Subcommittee's interest in these issues. And we want to thank the Chairman and Ranking Member for jointly introducing the "Veterans Substance Use Disorders Prevention and Treatment Act of 2008," a measure that would accomplish many of the goals that we have mentioned today.
Mr. Chairman, that concludes my statement. Thank you.
[The statement of Ms. Ilem appears in the Appendix.]
Mr. MICHAUD. Thank you. Doctor?
STATEMENT OF THOMAS J. BERGER, PH.D.
Mr. BERGER. Vietnam Veterans of America thanks you for the opportunity to present our views on substance abuse and comorbid disorders.
As you are well aware, substance abuse and PTSD form one of the pillars for my organization. And after 30 years in existence, still represent a very important component of our legislative agenda.
Foremost VVA thanks you for your leadership in holding this hearing today on a most serious concern within the veterans' community, because each month hundreds of active-duty troops, Reservists and National Guard members return to their families and communities from deployment in Iraq and Afghanistan.
Given the demanding and traumatizing environments of their combat experiences, many veterans experience psychological stresses that are further complicated by substance use and related disorders. In fact, research studies, as we have already heard this morning, indicate that veterans in the general U.S. population are at increased risk of suicide.
I was greatly heartened to hear the Chairman refer to the National Survey on Drug Use and Health Reports. I am not going to spend any time going over those figures, since they have already been mentioned.
But we must remember that those data that the Chairman presented to us today, only those veterans who chose to seek help for their disorders from the VA are the ones that are mentioned.
VVA has no reason to believe that the numbers cited in that report would not be higher if more of our OEF and OIF veterans were to seek VA care.
I should also like to point out that yesterday an article appeared in the "Stars and Stripes," just briefly. It was the results of the Defense Department's health behavior survey, which indicated amongst young sailors, airmen, especially Marines and soldiers, 18.5 percent overall indicated on the questionnaire that they would be put in the category of heavy drinking. The Army's actual rate was higher, 24.5 percent. So the numbers we heard mentioned by the Chairman earlier, I submit, may be actually higher.
The medical, social, and psychological toll from substance abuse disorders is enormous, both for the military and the civilian sectors. In the face of such overwhelming damage, two questions come to my mind: Why does substance abuse receive relatively little medical and public health attention and support compared with other medical conditions? And what can be done to reduce the harm from substance abuse disorders?
Despite their huge toll, substance abuse disorders remain underappreciated and underfunded. And reasons for this include, in my opinion, stigma, tolerance of personal choices, acceptance of youthful experimentation, pessimism about treatment efficacy, fragmented and weak leadership, powerful tobacco and alcohol industries, under investment in research, and difficult patients.
Now I am not going to spend a lot of time going over all of those, but despite those obstacles, VVA believes that a coordinated, workable agenda within both the military and civilian sectors are possible to lessen the impact of substance use disorders.
But this better approaches for treatment. For example, adequate treatment for substance abuse is particularly challenging for America's uninsured. Even for the insured, many policies, including most Medicaid programs, do not cover the time for counseling or the costs of drugs for substance use disorders. Again, as new, effective drugs come on the market, patients must have access to them.
We need to devote more support for research. Increase the percentage of the current National Institutes of Health (NIH) budget to substance abuse research. For example, beyond studying the basic science of addiction and exploring new pharmacologic treatments, research could help us better understand why some people who experiment with substances become addicted while others do not.
There needs to be better education of health professionals. Substance abuse receives minimal notice in undergraduate and graduate medical school curricula, specially board certifying exams, continuing medical school education, standard clinical textbooks, and medical journals.
There needs to be stronger leadership. Greater recognition of substance abuse and substance abuse disorders as a major health program or problem should encourage broader and more diverse leadership.
We also need to provide adequate treatment for community-based and incarcerated people with drug addiction, because it generates social and medical savings, lower crime, lower prison spending, less family dysfunction, and better health.
A RAND report of mandatory minimum sentences for cocaine concluded that dollar for dollar, treatment is fifteen times more effective than incarceration in reducing serious crime.
We also need to reform the criminal justice system for substance abuse. Federal and State legislation imposes mandatory terms for possession of illicit drugs, thereby removing sentencing discretion from the hands of judges. Drug courts are an effective antidote to this.
Substance abuse remains a serious medical, public health, and social problem in both our civilian and military sectors. Yet it lacks champions, is underfunded, and is relatively neglected by clinicians and the medical establishment.
Despite some real progress in the past decade, the United States still lags behind virtually every developed country in measures of health status. Our current national strategy to close that gap involves funding for biomedical research to yield new treatments and improving access to care for everyone, including America's veterans.
That concludes my testimony. Thank you very much.
[The statement of Mr. Berger appears in the Appendix.]
Mr. MICHAUD. Thank you, Doctor. Mr. Bowers?
Mr. BOWERS. Mr. Chairman, Ranking Member, and distinguished Members of the Subcommittee, on behalf of the Iraq and Afghanistan Veterans of America, and our tens of thousands of members nationwide, I thank you for the opportunity to testify this morning regarding veterans' substance abuse.
I would like to make it very clear also that I am here testifying in my civilian capacity as the Director of Government Affairs and my opinions and views today in no way reflect the Marine Corps, which I currently serve as a sergeant in the Reserves.
I would like thank the Committee for recognizing the issue of comorbidity. As the Committee knows, among the hundreds of thousands of troops returning from Iraq and Afghanistan with a mental health injury, a small but significant percentage is turning to alcohol and drugs in an effort to self-medicate. Veterans' substance abuse problems, therefore, cannot and should not be viewed distinct from mental health problems.
According to the VA Special Committee on post traumatic stress disorder, at least 30 to 40 percent of Iraq veterans, or about half a million people, will face a serious psychological injury, including depression, anxiety, or PTSD. Data from the military's own Mental Health Advisory Team shows that multiple tours and inadequate time at home between deployments increase rates of combat stress by approximately 50 percent.
We are already seeing the impact of these untreated mental health problems. Between 2005 and 2006, the Army saw an almost three-fold increase in "alcohol-related incidents," according to the DoD Task Force on Mental Health.
The VA has reported diagnosing more than 48,000 Iraq and Afghanistan veterans with a drug abuse problem. That is 16 percent of all Iraq and Afghanistan veteran patients at the VA. These numbers are only the tip of the iceberg. Many veterans do not turn to the VA for help coping with substance abuse, instead relying on private programs or avoiding treatment altogether.
Effective diagnosis and treatment of substance abuse is a key component of IAVA's 2008 legislative agenda. First and foremost, IAVA supports mandatory and confidential mental health screening by a mental health professional for all troops, both before and at least 90 days after a combat tour. Moreover, the VA must be authorized to bolster their mental health workforce in hospitals, clinics, and Vet Centers with adequate psychiatrists, psychologists and social workers to meet the demands of returning Iraq and Afghanistan veterans.
At this point, I am going to separate from my written testimony and try and share with the Committee an experience I had a week before last at my Marine Corps Reserve Center. We all have heard about the post-deployment health reassessment (PDHRA) survey. This is a form that individuals are required to fill out when they return. We filled this out the weekend before last. And I wanted to highlight a few of the ques
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