Chairman Michaud, Ranking Member Miller, and members of the Subcommittee, on behalf of the National Association of State Alcohol and Drug Abuse Directors (NASADAD), and our component organizations, the National Prevention Network (NPN) and the National Treatment Network (NTN), thank you for your leadership on issues related to veterans suffering from substance use disorders. We are pleased to offer comments on HR 5554, the Veterans Substance Use Disorder Prevention and Treatment Act of 2008.

Who We Are: NASADAD members include the State Substance Abuse Directors from the 50 States and five U.S. territories. These State Directors, also known as Single State Authorities (SSAs), have the front-line responsibility for managing the nation’s publicly funded substance abuse prevention, treatment and recovery systems. SSAs have a long history of providing effective and efficient services—with the Substance Abuse Prevention and Treatment (SAPT) Block Grant being the backbone of the system. SSAs also provide leadership to continually improve quality of care, expand access to services, improve client outcomes, increase accountability and nurture new and effective service initiatives.

Scope of the Problem: According to the Substance Abuse and Mental Health Services Administration’s (SAMHSA) National Survey on Drug Use and Health (NSDUH), approximately 23.6 million Americans aged 12 or older needed treatment for an alcohol or illicit drug problem in 2006. During the same year, approximately 4 million received some kind of treatment for an alcohol or illicit drug problem. As a result, approximately 19.6 million people needed but did not receive services in 2006.

Scope of the Problem Among Veterans: According to the NSDUH, in 2003, there were an estimated 25 million veterans in the United States. One quarter of veterans aged 18 to 25 met the criteria for a substance use disorder in the past year compared to 11.3 percent of veterans aged 26 to 54 and 4.4 percent of veterans aged 55 or older.  Heavy use of alcohol was most prevalent among veterans compared to nonveterans: an annual average of 7.1 percent of veterans aged 18 or older or an estimated 1.8 million veterans met the criteria for a substance use disorder in 2006. 

Addiction is a Brain Disease: According to research by the National Institute on Drug Abuse (NIDA), substance use disorders or addictive disorders are defined as chronic, relapsing brain diseases that are characterized by compulsive drug seeking and use, despite harmful consequences.  Substance use disorders literally change the brain’s structure and how it works. These brain changes can be long lasting, and can lead to the harmful behaviors seen in people who abuse drugs. Not only do genetics play a large role in one’s vulnerability to suffer from substance use disorders, but environmental factors, such as trauma, also play a role in one’s vulnerability to suffer from substance use disorders.  

Trauma and Stress are Risk Factors for Substance Use Problems: Research shows that a very stressful event or trauma such as military combat may lead to the development of post traumatic stress disorder (PTSD) or another form of psychological distress.  A NIDA Special Report on Stress and Substance Abuse found “…studies have reported that individuals exposed to stress are more likely to abuse alcohol and other drugs or undergo relapse.” The NIDA Special Report also found that “…high rates of co-occurring substance use disorders and PTSD are reported in studies of combat veterans, with as many as 75% of combat veterans with PTSD meeting the criteria for alcohol abuse or dependence (NIDA: 2005).”    

Services for Substance Use Disorders are Effective: Research shows that substance use disorder prevention and treatment services are effective. Discoveries in the science of addiction have led to advances in treatment that help people stop using alcohol and other drugs and resume their productive lives.  Research and experience also have found that successful treatment approaches are those that are tailored to address each person’s individual circumstances. 

Publicly-funded State System Yields Results: The Substance Abuse Prevention and Treatment (SAPT) Block Grant, which is managed by SSAs, represents approximately 40 percent of State substance abuse agency expenditures.  The SAPT Block Grant is an effective and efficient program that provides vital prevention and treatment services for the nation’s most vulnerable populations.  According to SAMHSA, the SAPT Block Grant has been successful in expanding capacity to treatment and achieving positive results.  In particular, outcomes data from the SAPT Block Grant found, at discharge, 68.3 percent of clients were abstinent from illegal drugs and 73.7 percent of clients were abstinent from alcohol.  SAPT Block Grant funded programs help people find or regain employment; stay away from criminal activity; reunite with families; and find stable housing.  Some State-specific examples of outcomes made possible by the SAPT Block Grant are included below:    

• Maine’s Office of Substance Abuse (OSA) reported 12,976 admissions to treatment and provided prevention services to 18,551 in State Fiscal Year 2007. In State Fiscal Year 2007, the following client outcomes were reported at discharge: 77 percent of clients were abstinent from alcohol or other drugs; employment increased by 20 percent at discharge; and homelessness decreased at discharge.
• Florida’s Department of Children and Families reported 89,716 new treatment admissions and provided prevention services to 133,024 adults and children received in State Fiscal Year 2006.  In SFY 2006, the Department reported the following client outcomes: 81 percent of adult clients were abstinent one year after discharge; 67 percent of child clients were abstinent one year after discharge; a 28 percent decrease in homelessness for clients receiving treatment; and employment rates increased by 20 percent for clients receiving treatment.
• South Carolina’s Department of Alcohol and Other Drug Abuse Services (DAODAS) reported 48,299 admissions to treatment and provided prevention services to approximately 208,000 people in State Fiscal Year 2006.  In SFY 2006, the Department reported the following client outcomes from a sample survey comparing admission to 90 days after discharge:  80.1 percent of clients reported no alcohol use; 71.6 percent of clients reported that they were employed; and 98 percent of students reported a reduction in suspensions, expulsions or detention.

Current State Initiatives:  A number of States are implementing various programs and initiatives to help veterans/ military personnel and their families.  NASADAD would like to call attention to a report issued on July 30, 2007 by the National Governors Association (NGA), with the support of the Office of the Deputy Under Secretary of Defense, titled State and Territorial Support for Members of the National Guard, the Reserves and their Families (see http://www.nga.org/Files/pdf/07GUARDREPORT.PDF).  The report notes that Governors are moving above and beyond federal requirements related to support for the National Guard and Reserves as many return from overseas assignments.  The NGA report places the benefits States are offering into six categories, including State Employee Benefits and Family Support benefits. 

NASADAD is also aware of current activities that include the involvement of the State substance abuse agency to address the needs of military personnel returning from countries impacted by war.  A sample of these activities is included below:

• Vermont’s Division of Alcohol and Drug Abuse Programs reports the development of a State interagency team; trainings for providers on veterans issues; and training for professionals working with children and families. 
• California’s Department of Alcohol and Drug Programs (ADP) is working to infuse veterans issues into the State-wide needs assessment and planning effort.  ADP participated in a veterans conference in January 2008 to discuss and prepare for the needs of OIF/OEF veterans.
• Washington State’s Division of Alcohol and Substance Abuse (DASA) reports working with the U.S. Army at Ft. Lewis, the Washington State National Guard, and the State Office of Veterans Affairs to engage returning veterans.
• Indiana’s Division of Mental Health and Addiction (DMHA), in cooperation with the DMHA Advisory Council, convened a forum that included the VA Veterans Integrate Service Network (VISN) 11, Indiana Department of Veterans Affairs, VA Roudebush Medical Center, VA Northern Indiana Medical Center, and the Indiana National Guard to discuss the needs of returning veterans and to explore opportunities for collaboration. DMHA’s Advisory Council, State Planning Council, and Transformation Working Group include VA representatives. The Division has also designated a liaison to VISN 11.
• Since 2005, ODADAS has participated in a multi-agency collaborative, spearheaded by Ohio’s Adjutant General, to develop a network of specially trained community-based alcohol and other drug and mental health providers to address the unique behavioral health needs of soldiers returning from Iraq and Afghanistan and their families. This initiative, referred to as OHIOCARES, has trained over 400 community-based providers including veteran’s administration and state mental health institution personnel. The OHIOCARES collaborative has convened two statewide conferences, published a brochure for military personnel and their families on how to access services, a resource guide to assist returning service members during their transition from active duty and a 1-800 number (1-800-761-0868) and website (www.ohiocares.ohio.gov). A marketing/branding committee was formed in 2007 and is currently finalizing materials for a statewide public awareness campaign. Included in this effort are the development of a radio and television PSA, posters, Info Cards, refrigerator magnets and web banners. These materials will be finalized and made available in May 2008.
• Iowa’s Division of Behavioral Health reports working with traumatic brain injury advocates and service providers.  The Division is also working to link with VA systems and participating in training through a suicide prevention grant.
• Oklahoma’s Department of Mental Health is providing briefings to families impacted by deployment. 
• Pennsylvania’s Bureau of Drug and Alcohol Programs (BDAP) participates on the Returning Pennsylvania Military Task Force, along with the Pennsylvania National Guard, Social Security Administration, State Civil Service Commission, U.S. Department of Veterans Affairs, Pennsylvania Department of Education, Pennsylvania Department of Labor and Industry, and others.  BDAP also sponsored a regional training event in September 2007 - Serving Those Who Serve: Veterans and their Families.  The event attracted 170 individuals and provided five specific courses designed for counselors and therapists.   
• New Hampshire’s Office of Alcohol and Drug Abuse Policy reports work with the New Hampshire National Guard to augment alcohol and other drug intervention service and treatment services with current services for those returning home from war.
• New York’s Office on Alcoholism and Substance Abuse Services (OASAS) reports funding Samaritan Village since 1996 which offers a 48 bed treatment facility for veterans in Manhattan; a new 50-bed residential facility will be placed in Queens; $280,000 was allocated for prevention counseling in the Fort Drum impacted schools; and a program model is being developed to bring 100 new residential beds for veterans into the system that will be responsive to the needs and characteristics of veterans, including traumatic brain injury, PTSD and other issues.
• New Jersey’s Division of Addiction Services (DAS) reports participation on the Veterans Subcommittee of the Governor’s Council on Alcoholism and Drug Abuse, which is developing a directory of resources to be distributed to veterans affiliated government and private agencies.  DAS is working with military officials at Fort Dix, New Jersey, in an effort to provide them with training opportunities for evidence-based Strengthening Families prevention program which could then be implemented on base.
• Kentucky’s Division of Mental Health and Substance Abuse is working with the State provider network to determine the impact of returning veterans and others seeking services in the public sector.  The State reports that a number of providers have reported increases in the number of veterans in the publicly funded system and report an increased need for family and children’s services.    

Barriers to Service Delivery at the VA: The Department of Veterans Affairs (VA) has identified substance use disorders as a significant problem among veterans. In 2004, Dr. Richard Suchinsky, Department of Veterans Affairs Associate Chief for Addictive Disorders, ranked substance use disorders among the three most common diagnoses made by the Veterans Health Administration (VHA).  The January 2008 VA Health Care Utilization Among US Global War on Terrorism (GWOT) Veterans, VA Office of Public Health and Environmental Hazards, found that of the approximately 300,000 veterans from Operations Enduring and Iraqi Freedom who have accessed VA health care, nearly 50,000 have been diagnosed with a substance use disorder. Furthermore, data from the NSDUH found that an estimated 0.8 percent of veterans received specialty treatment for a substance use disorder in the past year, yet an estimated 7.1 percent of veterans met the criteria for a substance use disorder in the past year, leaving close to 6.3 percent of veterans going without treatment. NASADAD recognizes the capacity problems across the whole system and applauds the VA for recognizing that substance use disorders are a problem among veterans and for making efforts to expand capacity to treatment for returning veterans.  The stigma associated with substance use disorders also presents a barrier to veterans seeking treatment for substance use disorders. 

Recommendations: As the Subcommittee engages in discussions about substance use disorder services in general, and H.R. 5554 in particular, NASADAD offers the following recommendations for consideration:

Coordination with State Substance Abuse Directors: NASADAD recommends provisions that foster and enhance coordination and communication between SSAs and the VA.  As previously mentioned, SSAs plan, implement, oversee and evaluate comprehensive State-wide systems of clinically appropriate care.  SSAs already work with a variety of public and private stakeholders given the impact substance use disorders have on issues such as housing, education, employment, family and much more.  As mentioned earlier, a number of SSAs are already engaged in initiatives regarding services for veterans.  The inclusion of provisions in H.R. 5554 that foster or enhance coordination with the State substance abuse agency would ensure a thoughtful planning process and promote a more effective and effective approach to service delivery, as well ensure a referral network of competent providers.

Federal Agency Collaboration:  NASADAD recommends continued work to encourage coordination among federal agencies that have a role in helping veterans receive appropriate services.  We recommend continued and consistent collaboration between the VA and the Substance Abuse and Mental Health Services Administration (SAMHSA) on issues related to substance abuse and mental health.  This collaboration ensures that efforts are made to maximize and leverage the financial resources and expertise available on these important issues.  One specific example relates to the benefit of coordinating the efforts of SAMHSA’s regional Addiction Technology Transfer Centers (ATTCs) and Centers for the Application for Prevention Technologies (CAPTs) with proposals to establish within the VA system centers of excellence that would include substance abuse as a specific component.  The ATTCs and CAPTs serve as centers that help take the latest research and infuse the knowledge into the publicly funded system through practice improvement initiatives, trainings, workforce development and other mechanisms.  Federal agency coordination specific to substance use disorders would also include work with the National Institute on Drug Abuse (NIDA), National Institute on Alcohol Abuse and Alcoholism (NIAAA).  Finally, NASADAD supports additional federal agency coordination with other agencies as well, including Department of Housing and Urban Development (HUD), Department of Labor (DoL), Department of Education (Ed), and others.  

Adequate Resources: NASADAD wishes to applaud the VA for its work and commitment to veterans in States across the country.  There is no doubt that excellent work is moving forward.  We also know that many challenges remain.  For example, the core funding stream that represents the backbone of the State publicly funded system – SAMHSA’s Substance Abuse Prevention and Treatment (SAPT) Block Grant – has been reduced by $20 million since FY 2004.  In addition, resources within SAMHSA’s Center for Substance Abuse Prevention (CSAP) and Center for Substance Abuse Treatment (CSAT) remain stagnant. In addition, decreases in capacity across the whole system make it difficult to address the needs of returning military personnel, such as the returning National Guard members.

NASADAD strongly agrees with the Veterans Affairs Policy Position of the NGA (HHS-05) that notes “Governors recommend that more resources be provided to address the impact of completed suicides, PTSD, TBI, and substance/alcohol abuse through the VA.”   Additional resources are needed for the VA in order to enable the agency to attain our common goal of improving access to, and quality of, services for substance use disorders.  NASADAD would like to recognize recent investments made by Congress in support of substance use disorder services within the VA and Department of Defense (DoD) over the past few years. 

Workforce: As previously noted, treatment for substance use disorders is effective and efficient. NASADAD supports the delivery of substance use disorder services by practitioners that adhere to standards of care set by the State. We believe this approach ensures that health care professionals have the clinical expertise needed to provide the best care possible to returning veterans suffering from substance use disorders. NASADAD applauds the VA for efforts to expand their addiction-specific workforce in the last couple years. NASADAD is committed to partnering with the VA and others to continue this expansion given the acute problem of recruiting and retaining a qualified health workforce.

Flexibility: NASADAD encourages initiatives to include the benefits of flexibility.  As previously mentioned, States across the country are implementing a number of initiatives to assist veterans and their families.  The Association encourages federal initiatives to include flexible approaches to policy decisions in order to maximize State participation.  In addition, NASADAD recognizes that individuals present with many circumstances that in turn determine an individual’s treatment plan.  As a result, the Association believes that legislation should encourage clinically appropriate care that is based on accepted standards set within the State.  

Data Reporting and Management:  One of NASADAD’s top policy priories is the implementation of an outcome and performance measurement data system.  With this goal in mind, NASADAD and the members have successfully partnered with SAMHSA to implement the National Outcome Measures (NOMs) initiative.  The goal of NOMs is to improve service delivery within publicly funded system using a common set of indicators of accountability and performance.  States across the country are reporting data on the impact treatment services have on abstinence from alcohol and other drugs; employment; criminal justice involvement; housing; social connectedness and more.  States are also reporting data on the impact prevention services have on the youth alcohol and other drug use; age of initiation; perceived risk/harm of use; drug related crime and other measures. 

NASADAD recommends widespread awareness of the NOMs initiative across all agencies.  The Association also recommends cross-agency discussions regarding the benefits of this performance and outcome system that is being utilized in every State in the country.  Synchronized data collection efforts will improve the accuracy of the information we have on the number of Americans impacted by alcohol and other drugs and enhance our understanding of service delivery.      

Thank You: We applaud you for introducing legislation that seeks to expand access to high quality substance use disorder services for our nation’s veterans.  We stand ready to partner with you on this initiative and others to ensure that our nation’s veterans receive the care they need and deserve.