Mr. Chairman and Members of the Subcommittee:

Thank you for inviting the Disabled American Veterans (DAV), an organization of 1.3 million service-disabled veterans, to testify at this important hearing to discuss solutions for veterans dealing with substance use disorders and co-existing mental health conditions. We appreciate the opportunity to offer our views on Department of Veterans Affairs (VA) specialized programs for these conditions.

The misuse and abuse of alcohol and other substances continues to be a major health problem for many Americans, including many of our nation’s veterans. Substance use disorders result in significant health and social deterioration and financial costs to veterans, their families and the nation. Although substance abuse is a complex problem, there is clear evidence that treatments can be brought to bear to reduce these negative consequences.

The Scope of the Substance Use and Abuse Problem is Growing:

DAV has a growing concern about the reported effects of combat deployments in Iraq and Afghanistan on our newest generation of war veterans. There is converging evidence that substance abuse is a significant problem for many veterans of Operations Iraqi and Enduring Freedom (OIF/OEF)—and that the incidence of this problem will likely continue to rise. Over the past year there have been a number of research and media reports highlighting the prevalence of substance use and other mental health problems among OIF/OEF veterans and the challenges that many of these veterans and their families are facing post-deployment. Among the most notable are –

• In the most recent Department of Defense (DoD) anonymous Survey of Health Related Behaviors Among Active Duty Personnel, 23% acknowledge a significant alcohol problem;[1]

• Alcohol related incidents (e.g. DUI, drunk and disorderly) reported in the Army Forces Command data base increased from 1.73 per 1,000 soldiers in 2005, to 5.71 in 2006;[2]

• Alcohol contributed to 65% of the markedly increased incidence of suicidal behavior in the military;[3]

• In a recent study of returning National Guard, 24% reported alcohol abuse;[4]

• Reported rates of psychological problems increase with multiple deployments;[5] and,

• Reports of child abuse and increased incidence of marital problems in military families as a result of multiple deployments.[6]

Current research also highlights that OIF/OEF veterans are at higher risk for post traumatic stress disorder (PTSD) and other mental health problems as a result of combat exposure. VA reports that these veterans have sought care for a wide array of possible co-morbid medical and psychological conditions, including adjustment disorder, anxiety, depression, PTSD, and the effects of substance abuse. Through January 2008, VA has reported that of the 299,585 separated OIF/OEF veterans who have sought VA health care since fiscal year 2002, a total of 120,049 unique patients had received a diagnosis of a possible mental health disorder. Almost 60,000 enrolled OIF/OEF veterans had a probable diagnosis of PTSD; almost 40,000 OIF/OEF veterans have been diagnosed with depression; and, more than 48,000 reported nondependent abuse of drugs.[7] These data are consistent with DoD studies of active duty OIF combat troops.

In a recent study, VA New Jersey-based researchers examined substance abuse and mental health problems in returning veterans of the war in Iraq. Researchers noted that although increasing attention is being paid to combat stress disorders in veterans, there has been little systemic focus on substance abuse problems in this population. Among the 292 National Guard members studied, an alarmingly high percentage (39 percent) reported one or more substance abuse-related problems. Rates were even higher among the subset who were youngest (e.g., “problem drinking” in 46 percent) and had high exposure to combat (e.g., 52 percent reported problem drinking). Yet access to substance abuse services for the group studied was very low (only 9 percent), compared with access to other mental health services (41 percent).[8]

Similarly, a study of returning Maine National Guard members found substance abuse problems in 24 percent of the troops surveyed.[9] In the most recent DoD anonymous Survey of Health Related Behaviors Among Active Duty Personnel, 23 percent of respondents acknowledged a significant alcohol problem.[10]

Lack of Seamless Detoxification-to-Rehabilitation Transition Services:

We have special concerns about VA’s local policies on making detoxification services readily and widely available to veteran candidates who are interested in substance abuse rehabilitation services. VA officials have informed us that detoxification services provided by internal medicine bed sections should be readily available within all VA medical centers to veterans who need them as a precursor to admission to VA substance use disorder treatment programs. Physical detoxification, whether from dependent alcohol or other drug use, is the essential key in preparing a veteran for therapeutic rehabilitation and sobriety. However, we understand that, in many cases, VA’s substance abuse treatment programs will not accept a veteran who is actively drinking or using drugs. We have received anecdotal stories from VA sources in field facilities to indicate that often, intoxicated veterans who come to VA for care are instead turned away, and occasionally they are even arrested for public drunkenness or property violations. We strongly believe that having a substance use disorder should not be a barrier to receiving care for that condition or entrance into any other VA specialized treatment program.

Current and former VA clinicians with expertise in substance use disorder treatment have informed us that VA medical centers with robust substance use treatment programs generally have clinical staff that maintain a close liaison with VA admitting offices, emergency rooms, internal medicine, and primary care clinics, for the purpose of identifying veterans who need detoxification services. When these patients are identified, liaison staff members ensure they receive proper referral to detoxification resources in internal medicine and then help these veterans make their transition to follow-on substance abuse treatment programs. In medical centers without fully integrated substance abuse services, patients may not be identified or properly referred, and even if they are detoxified, they might fall through the cracks, or refuse this critically important specialized follow-on care, thus wasting significant health care resources and ultimately failing these veterans.

Inadequacy of Substance Disorders and Co-Morbid Mental Health Treatments in VA:

The past decade has been marked by unparalleled growth in VA clinical services. Unfortunately, substance use treatment and rehabilitation resources have declined during that same period and VA has made little progress in restoring them, even in the face of likely increased demand from veterans returning from OIF/OEF. In 1996 specialized substance abuse treatment services accounted for 3.8 percent of VA’s clinical budget—but by 2006, this fraction had dropped to 1.8 percent. A number of national population surveys of the prevalence of substance abuse show no comparable decline in incidence of drug and alcohol addiction. Over the same period (1996 to 2006) the number of veterans receiving specialized substance abuse treatment services declined by approximately 18 percent, with the exception of a slight growth (2 percent) from 2005 to 2006, due to infusion of specifically directed supplemental funding. Furthermore, there has been a marked increase in the variability of access to a comprehensive continuum of care for substance abuse services. In 2006 (latest data available to DAV), VA’s Veterans Health Administration (VHA) networks varied markedly in the proportion of their patient populations that were treated in substance abuse specialty care. The normalized rates for veterans treated for substance abuse ranged from 8.5 per 1,000 treated for any condition to 3.3 per 1,000.[11] Experts in this field have informed DAV that this variability cannot be explained by regional differences in the prevalence of substance abuse disorders. Finally, although it is known that many mental health conditions including PTSD, anxiety disorders and depression are frequently associated with substance use disorders, currently there are few integrated treatment programs available in VA to address these co-existing disorders.

Given the need we see for these specialized services not only in the older veteran population cohorts but especially in the latest generation of war veterans, these findings are of great concern to the DAV.

The Relationship Between Substance Use Disorders and Other Major Medical and Mental Health Conditions:

According to experts and published literature, substance use disorders are common co-morbidities with other medical and mental health conditions. Some significant examples include–

• Veterans with PTSD often use alcohol or other drugs to blunt memory, escape pain and self-medicate for stress. In recognition of this tendency, VA’s evidence-based treatment guidelines for PTSD generally require that veterans in treatment for PTSD also receive screening and treatment for substance use disorders.

• Abuse of substances is a significant risk factor in suicidal ideation.[12]

• Literature indicates that up to 50 percent of veterans with severe mental illnesses (e.g. schizophrenia, bipolar disorder) also have a substance use problem.[13]

• The most common means of contracting Hepatitis C (a condition notably higher in the veteran population than the general population), and other serious liver diseases, is through injection of illicit drugs. Furthermore, the most effective treatments for Hepatitis C require that the patient not be currently abusing alcohol or other drugs before treatment can commence.

• Excessive use of alcohol or other drugs complicates the treatment of diabetes, cardiac disorders and other major medical diseases and conditions.

• VA reports that approximately 70 percent of homeless veterans receiving services from VA suffer from alcohol or drug abuse problems.[14]

Conclusions:

All the foregoing research, surveys, reports and experience validate that substance use disorders are prevalent among veterans, particularly younger veterans and those who have experienced combat or other significant trauma. Therefore, it is likely that OIF/OEF veterans will significantly increase demand for specialty substance abuse treatment services in VA. Unfortunately, many veterans, including younger OIF/OEF veterans, with substance use disorders do not have access to an array of comprehensive treatments across the VA health care system. Lack of access to such services will likely result in sub-optimal rehabilitation for thousands of veterans, including many with severe medical and mental health co-morbid conditions that require concurrent treatment of their alcohol and drug abuse disorders. Untreated substance abuse can result in severe physical consequences for the veteran, stress on the family, and marked increase in medical and social costs including loss of employment and in some cases, serious legal difficulties.

VA Policies and Treatment Programs Need Further Adaption:

VA and DoD evidence-based treatment guidelines for substance use disorders document the substantial research supporting effectiveness of a variety of treatments. Based on these guidelines, we believe veterans should have access to a full continuum of care for substance use disorders including: 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; widely available 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.

Additionally, VA must continue to educate its primary care providers about, and fully implement these guidelines, including better detection of substance use disorders in veterans under VA care, to ensure that problems are identified early and that patients are referred for appropriate treatment. Substance use—common as a secondary diagnosis among newly injured veterans and others with chronic illness or injury—can often be overshadowed by acute care needs that may seem more compelling. Therefore, we urge VA and DoD to continue research into this critical area and to identify the best treatment strategies to address substance use disorders and other mental health and readjustment issues collectively.

A final concern we have is VA’s practical policy to serve as a seemingly “rock bottom” program in substance abuse treatment and rehabilitation. It appears that VA’s main focus in providing substance abuse treatment is to serve a population that has not abated their substance misuse and consequently have deteriorated to a point of social or medical disfunctionality. While we applaud VA’s efforts to save individuals from the misery of chronic addiction, we are concerned about the locus of this program because of reports that “hazardous” and “non-dependent” use of drugs and alcohol in seemingly functional OIF/OEF veterans is significant. We believe VA’s focus on the most severe dependent substance abusers to the exclusion of this newer generation of problem drinkers and occasional pre-dependent drug users will cause many newer combat veterans additional misery and decline that could be avoidable. We urge VA to revamp its programs to focus on earlier interventions in individuals’ misuse of substances.

Recommended Legislative Action:

With these views in mind, DAV recommends the Subcommittee advance legislation that –

• Mandates VA provide a full continuum of care for veterans with substance use disorders equitably across the country. These services should be available at all medical centers with outpatient counseling and pharmacotherapy available at all larger community based outpatient clinics. Residential substance abuse treatment should be readily available for those requiring a higher level of care in each network. Brief motivational interventions, particularly for hazardous drinkers, should be offered in primary care settings whenever possible. Additionally, VA should employ peer counselors for outreach to OIF/OEF veterans struggling with substance use problems.

• Allocates adequate funding to assure that this full continuum of substance use disorder care is provided, on an equitable basis, for all veterans who need it.

• Requires an annual update on the progress in providing equitable access to a full continuum of substance abuse care. This report should include meaningful data on the number of veterans provided specialty substance use disorder care; the results of universal screening for substance abuse in primary care; and, a measurement of the availability of services at each facility and in each network as specified by VA’s adopted national clinical practice guidelines for substance use disorder care.

• Authorizes a pilot program specifically designed to offer web-based options for substance use treatment and group support targeted at OIF/OEF veterans who reside in rural or remote areas.

• Provides specifically designated funding for research projects to identify the best treatment strategies and practices to collectively address substance use disorders and other co-morbid mental health readjustment issues.

Closing:

Mr. Chairman, the current overseas deployments to combat theaters in Iraq and Afghanistan (and other Global War on Terror deployments) are resulting in not only serious physical injuries to veterans but heavy casualties in what are considered the “invisible” wounds of war: PTSD, depression, family disruptions and divorce, hazardous drinking and drug use, and a number of other social and emotional consequences for those who have served. DoD, VA and Congress must remain vigilant to ensure that federal programs aimed at meeting the extraordinary needs of disabled veterans are sufficiently funded and adapted to meet them, while continuing to address the chronic health maintenance needs of older disabled veterans who served in earlier military conflicts. Also, Congress must remain apprised about how VA spends the significant new funds that have been added and earmarked for the purpose of meeting post-deployment mental health care and physical rehabilitation needs of veterans who served in OIF/OEF.

DoD and VA share a unique obligation to meet the health care and rehabilitative needs of combat veterans who have been wounded or who may be suffering from severe readjustment difficulties as a result of combat and hardship deployments. We owe our nation’s disabled veterans access to timely and appropriate health care services including specialized substance use treatment programs for those suffering with both mental health and substance use disorders. We must ensure that VA establishes and sufficiently funds effective programs now aimed at prevention, early intervention, outreach and education and training for veterans and their families to close the current gaps that exist. Finally, as we indicated earlier in this statement, DAV believes that having a substance use disorder should not be a barrier to receiving care for that condition or entrance into any other VA specialized treatment program. We deeply appreciate that the Subcommittee is addressing these issues with both oversight and legislation when appropriate. To that end, we note and thank the Chairman and Ranking Member for jointly introducing the “Veterans Substance Use Disorders Prevention and Treatment Act of 2008,” an Act that would accomplish many of the goals we have identified in this testimony, to address substance use disorders in the veteran population.

Mr. Chairman, this concludes my statement, and I will be pleased to respond to any questions you may wish to ask with regard to these issues.

References:

[1] Bray, R., Hourani, L., Olmstead, K., et al (2006, August). 2005 Department of Defense Survey of Health Related Behaviors Among Active Duty Military Personnel: A Component of the Defense Lifestyle Assessment Program (DLAP). NC: Research Triangle Institute.

[2] An Achievable Vision: The Report of the Department of Defense Mental Health Task Force, June 2007

[3] Ibid.

[4] Wheeler, E. Self Reported Mental Health Status and Needs of Iraq Veterans in the Maine Army National Guard. Community Counseling Center, 2007 (unpublished).

[5] An Achievable Vision: The Report of the Department of Defense Mental Health Task Force, June 2007

[6] Robert Davis and Gregg Zoroya, “Study: Child abuse, troop deployment linked,” USA Today, 7 May 2007: http://www.usatoday.com/news/nation/2007-05-07-troops-child-abuse_N.htm

[7] Department of Veterans Affairs, VHA Office of Public Health and Environmental Hazards, “Analysis of VA Health Care Utilization Among US Global War on Terrorism (GWOT) Veterans: Operation Enduring Freedom, Operation Iraqi Freedom,” January 2008.

[8] Kline, A., Falca-Dodson, M. Substance Abuse and Mental Health Problems in Returning Iraqi Veterans. VA New Jersey Healthcare System and New Jersey Department of Military and Veterans Affairs, 2007. (unpublished)

[9] Wheeler, E. Self Reported Mental Health Status and Needs of Iraq Veterans in the Maine Army National Guard. Community Counseling Center, 2007 (unpublished).

[10] Bray, R., Hourani, L., Olmstead, K., et al. (2006, August). 2005 Department of Defense Survey of Health Related Behaviors Among Active Duty Military Personnel: A Component of the Defense Lifestyle Assessment Program (DLAP). NC: Research Triangle Institute.

[11] Department of Veterans Affairs National Mental Health Program Performance Monitoring System, Fiscal Year 2006.

[12] An Achievable Vision: The Report of the Department of Defense Mental Health Task Force, June 2007

[13] Department of Veterans Affairs National Mental Health Program Performance Monitoring System, Fiscal Year 2006 Report.

[14] United States Department of Veterans Affairs, Overview of Homelessness, March 6, 2008. http://www1.va.gov/homeless/page.cfm?pg=1