Mr. Chairman, I would like to thank you and the members of this subcommittee for holding today’s hearing on “Substance Abuse/Co-Morbid Disorders: Comprehensive Solutions to a Complex Problem.” The challenges in creating a health care system capable of effectively treating co-occurring substance use disorders are significant, but experience has proven that there are practical steps which can improve outcomes for clients and their families.

As a brief note of introduction, NAADAC, the Association for Addiction Professionals, is the national professional association serving addiction-focused health professionals and educators. NAADAC has 10,000 members across the country and affiliate organizations in 46 states, two territories, and several foreign countries. Our certification commission certifies addiction professionals in all fifty states and in numerous foreign countries.

Scope of Substance Use Disorders and Co-Morbidity

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).[1] Nevertheless, they remain under-diagnosed and under-treated in the VHA, which reflects a similar treatment gap in civilian society. Young veterans (under age 25) suffer from substance use disorder rates as high as 25 percent,[2] and veterans are more likely than their civilian peers to engage in heavy alcohol use and to take part in risky behavior like drunk driving.[3] In total, it is estimated that 1.8 million veterans suffered from a diagnosable substance use disorder in 2002 and 2003.[4]

Substance use disorders frequently co-occur with other physical and mental health conditions. In the case of diseases like HIV or hepatitis-C, co-morbidity with substance use disorders is often associated with the act of drug use itself—sharing needles, for example, or engaging in risky sexual behavior. In the case of mental health conditions like post-traumatic stress disorder (PTSD), depression, or bipolar disorder, substance use disorders frequently result from attempts to “self-medicate” with alcohol or other drugs rather than receiving needed mental health care.

The high number of mental health conditions reported by veterans of the conflicts in Iraq and Afghanistan has been associated with a surge of co-occurring substance use and mental disorders. Some experts estimate that about 40 percent of veterans who have served in Iraq or Afghanistan will experience a mental health problem, and that of those approximately 60 percent will have a substance use disorder.[5] In 2002 and 2003, the National Survey on Drug Use and Health estimated that 340,000 male veterans suffered from co-occurring substance use disorders and “serious mental illness,” defined as a diagnosable mental condition that substantially interfered with a normal life activity.[6] Post-traumatic stress disorder—one of the most commonly diagnosed combat-related mental disorders—is frequently co-morbid with substance use disorders. During the Vietnam War, for example, 60- 80 percent of veterans with PTSD also suffered from addiction disorders.[7]

There is reason to fear that co-occurring substance use disorders in veterans may be on the rise. Studies have shown that multiple deployments increase the risk of post-traumatic stress disorder, and National Guard forces report higher rates of psychological distress than do regular forces.[8] As redeployments continue and additional “citizen soldiers” serve overseas, the risk of co-occurring substance use disorders rise.

Co-occurring substance use disorders are difficult to treat, and the ongoing stigma against addiction and treatment discourages many people from seeking the help they need. This is particularly true for people from the military culture who fear seeming “weak” or in need of help.

Solutions

The Department of Veterans Affairs and Congress should be commended for having made mental health care for veterans a priority over the past several years. The publicly expressed concern for veterans with post-traumatic stress disorder, traumatic brain injury, and other mental health conditions has been far greater than in earlier conflicts. We thank Congress for its historic recent funding increases for veterans’ health, which have the potential to significantly expand access to treatment.

As this hearing’s title aptly suggestions, co-occurring addiction and mental disorders are best treated comprehensively. This means that caregivers are most effective when they have demonstrated competencies in both addiction and mental health care. Treatment for substance use disorders is most effective when delivered by health care professionals with a certification or license in addiction-specific care; research has shown that addiction treatment is as effective as treatment for other chronic diseases such as diabetes, hypertension, and asthma.[9] Licensure and certification ensure that the practitioner has both the educational foundation and clinical experience in evidence-based and promising practices to provide the best possible care.

A 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—staff intended for addiction treatment at some veterans hospitals are often reassigned or transferred, resulting in uneven treatment in some cases. Reports that the addiction-focused VHA workforce has declined by almost half in the past decade are particularly disturbing.[10] As the VA seeks to build its addiction treatment workforce, it should recruit addiction professionals who are certified or licensed in addiction treatment by their state of residence. The VHA should also provide resources to its current health care workforce to become certified or licensed in addiction-specific treatment.

Whether the clinician treating a client with a co-occurring substance use disorder has demonstrated competencies in both addiction and mental health trauma or works in partnership with other clinicians, it is important that the client have access to both areas of medical knowledge. Once comprehensive treatment has begun, it should be extended as long as necessary. For example, in-patient treatment for co-occurring PTSD and addiction can take several months, and outpatient treatment can take a year or longer. As with any extended treatment, the patient’s family should be included in any treatment program whenever possible.

Early screening and intervention lead to more successful treatment outcomes for co-occurring substance use disorders. Almost 500,000 of the veterans who received any form of VA care in 2001 are estimated to have met the clinical criteria for substance use disorders, yet only 19 percent of them (about 91,000) received specialized addiction treatment.[11] This is primarily because these veterans presented at primary care facilities and their substance use disorders went undetected. Primary care health practitioners must be trained in identifying substance use disorders and co-occurring mental health conditions, and qualified addiction professionals should be on-call to provide intervention in cases where evidence of substance use disorders exists.

Routine screenings must be conducted in a manner that encourages honest responses and results in a seamless transition into treatment. Similarly, the VA should be transparent and accountable for cases where they deny treatment to a veteran claiming to have combat-related PTSD or substance use disorders and release public reports on those statistics. Because PTSD and substance use disorders are often late-onset conditions, screenings should be conducted as regularly as possible in the years following a veteran’s return from combat.

Once receiving treatment for co-occurring substance use disorders, it is critical that clients receive culturally competent care. Familiarity with military culture is often essential for effective treatment. This is true both for addiction professionals in the VHA as well as for the civilian addiction professionals who treat veterans who seek treatment in the nation’s non-VHA treatment systems.

The current conflicts in Iraq and Afghanistan also require a new emphasis on gender-specific treatment strategies. Fifteen percent of the armed forces are women, and servicewomen are closer to combat than ever before. Rates of PTSD are higher in women than in men, and female veterans suffer from PTSD in numbers greater than their civilian counterparts.[12] The VHA should invest in studying gender-specific treatment and counseling strategies, and provide appropriate trainings to its addiction and mental health workforce.

The unprecedented number of women serving in the armed forces, combined with the high rates of Reservists and National Guard forces in combat and extended tours of duty, have made the current conflict particularly psychologically difficult for families. Addiction is a disease which affects the entire family—there are powerful genetic predispositions for addiction, and family stress increases the risk of drug use. Such stress exists both when a parent or child is deployed as well as when they return from duty—the process of “returning to normal” is rarely as seamless as a veteran’s family might hope. In most cases, addiction treatment for a veteran should occur in the context of his or her family. The VHA should increase its outreach to family and include families in its treatment programs whenever possible. The VHA must prioritize family-centered care as it implements comprehensive care for co-morbid substance use disorders.

Part of this family-centered treatment approach includes making access to treatment as 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 more densely populated, and less geographically dispersed, than civilian treatment sites. A study found that VHA facilities (mostly hospitals) providing addiction treatment housed three times as many clients, on average, than did non-VHA facilities.[13] This indicates addiction treatment in the VA is more centralized in fewer, larger facilities than treatment in the civilian sector. This raises the concern that some veterans have more difficulty finding a convenient, easily accessible treatment site through the Department of Veterans Affairs than their civilian counterparts. This problem is particularly pronounced for veterans in rural areas and for those who lack the employment flexibility, funds, or family structure to travel long distances.

Despite the significant funding increases for veterans’ health care, we encourage the Department of Veterans Affairs to more aggressively pursue partnerships with existing civilian treatment systems. No amount of new VA funding can rebuild the entire public and private treatment system which exists in the United States today, with well over 10,000 treatment facilities and tens of thousands of addiction professionals. The diminishing returns of such an attempt, particularly in rural areas and small communities, would not be an efficient use of funds. Rather, strategic partnerships that expand the capacity of existing treatment systems in underserved areas would provide veterans and their families with the care they need close to home. It would also expand access to care immediately, without the need for new facilities, employees, and programs to be established.

Conclusion

The current conflicts in Iraq and Afghanistan pose many new challenges to effective health care. While co-occurring substance use disorders and mental health conditions like PTSD are among the most complex of those challenges, comprehensive plans of action can dramatically improve veterans’ health. In this case, “comprehensiveness” includes ensuring that a clinician with addiction-specific qualifications is part of every treatment plan, that the family is included to the greatest extent possible, that screening and intervention for addiction and mental illness is included in primary care settings, and that veterans can access the care they need conveniently and close to home. We commend the Department of Veterans Affairs, this subcommittee, and other policymakers who have worked to improve veterans’ access to health care 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. Thank you for the opportunity to testify today, and I would be happy to answer your questions.

[1] Quoted in Smith, Thurston. “Overview.” Resource Links: Substance Use Disorders and the Veterans Population. Northeast Addiction Technology Transfer Center. Summer 2004. Vol. 3, Iss. 1.

[1] National Survey on Drug Use and Health. “Serious Psychological Distress and Substance Use Disorder among Veterans.” Office of Applied Studies, Substance Abuse and Mental Health Services Administration. 1 Nov. 2007.

[2] National Survey on Drug Use and Health. “Serious Psychological Distress and Substance Use Disorder among Veterans.” Office of Applied Studies, Substance Abuse and Mental Health Services Administration. 1 Nov. 2007.

[3] National Survey on Drug Use and Health. “Alcohol Use and Alcohol-Related Risk Behaviors Among Veterans.” Office of Applied Studies, Substance Abuse and Mental Health Services Administration. 10 Nov. 2005.

[4] National Survey on Drug Use and Health. “Serious Psychological Distress and Substance Use Disorder among Veterans.” Office of Applied Studies, Substance Abuse and Mental Health Services Administration. 1 Nov. 2007.

[5] Quoted in Danforth, Kristen Inger. “Change in Mindset Brings Veterans Care Into a New Era.” Resource Links: Issues Facing Returning Veterans. Northeast Addiction Technology Transfer Center. Fall 2007. Vol. 6, Iss. 1.

[6] National Survey on Drug Use and Health. “Serious Psychological Distress and Substance Use Disorder among Veterans.” Office of Applied Studies, Substance Abuse and Mental Health Services Administration. 1 Nov. 2007.

[7] Mwisler, A.W. “Trauma, PTSD and Substance Abuse.” PTSD Research Quarterly, 7, (4).

[8] Hope Yen. “Pentagon Panel Warns of Mental Strain.” Associated Press. 3 May 2007: http://vawatchdog.org/07/nf07/nfMAY07/nf050507-1.htm. and “Mental Health Advisory Team (MHAT) IV Brief.” General James T. Conway, Commandant of the Marine Corps. 18 April 2007: http://216.239.51.104/search?q=cache:505MsjAlGO4J:blog.wired.com/defense/files/mhat_iv_brief_to_marine_corps_commandant_gen_conway_18apr07.ppt+Mental+Health+Advisory+Team+(MHAT)+II+Brief&hl=en&ct=clnk&cd=1&gl=us

[9] National Institute on Drug Abuse. “Principles of Drug Addiction Treatment: A Research Based Guide.” NIH Publication NO. 00-4180.

[10] Tracy SW, Trafton JA, Humphreys K. “The Department of Veterans Affairs Substance Abuse Treatment System: Results of the 2003 Drug and Alcohol Program Survey.” Palo Alto, Calif, VA Program Evaluation and Resource Center and Center for Health Care Evaluation, 2004. Available at www.chce.research.med.va.gov/pdf/2004DAPS.pdf

[11] McKeller, J., Che-Chin, L. & Humphreys, K. “Health Services for VA Substance Use Disorder Patients: Comparison of Utilization in Fiscal Years 2002, 2001 and 1998.” 2002. Palo Alto, Ca.: Program Evaluation and Resource Center and Center for Health Care Evaluation, Department of Veterans Affairs Medical Center.

[12] Schnurr, P.P., et. al. “Cognitive Behavioral Therapy for Posttraumatic Stress Disorder in Women.” JAMA. 28 Feb. 2007. Vol. 297:820-830. and Kessler, T.C., Sonnega, A., et.al. “Posttraumatic Stress Disorder in the National Comorbidity Survey.” Arch Gen. Psych. Dec. 1995. 52(12):1048-60.

[13] Drug and Alcohol Services Information System. “Characteristics of Substance Abuse Facilities Owned and Operated by the Department of Veterans Affairs: 2000.” Office of Applied Studies, Substance Abuse and Mental Health Services Administration. 11 Nov. 2002.