Mr. Chairman, Ranking Member and Members of the Subcommittee, I will attempt in my limited remarks to provide an independent, ground level assessment of the needs of veterans for substance use disorder services, and the current capacity of VA to provide them.

Let me first share the basis for my assessment. I retired a few years ago after 32 years in VHA, where I worked clinically primarily in substance abuse and then in various management positions, culminating as Mental Health Care Line Director for VISN10. I was the co-chair of the VA national Committee on the Care of Severely Mentally Ill Veterans, mental health representative on the VACO Task Force overseeing all practice guidelines, and co-chair of the group drafting VA evidence based practice guidelines for Dually Diagnosed veterans. After I retired I had the additional opportunity to personally site visit 39 VA facilities as a Member of the CARES Commission, a member of a special Secretary's mental health task force established by Secretary Principi, and as consultant on mental health and substance abuse programming. The last two years I personally visited 23 military bases and reserve units, across the world, as a member of the congressionally mandated DoD Mental Health Task Force. On these visits I talked with literally thousands of service members, family, mental health providers and commanders about mental health and substance abuse issues. I continue to conduct NIAAA funded research at the Center for Health Care Policy and Research at Case Western Reserve University and am involved in two large DoD funded studies of returning National Guard and Reserve members.

Scope of the Problem

The need for comprehensive substance use disorder services is immense and growing. Multiple studies indicate high rates of alcohol and other drug related problems for returning service members. For example, returning reservists, who are veterans within weeks of their return, report rates as high as 52%, related to combat exposure, number of deployments.

This hearing importantly focuses on comorbidities.  Substance misuse is a common comorbidity for all significant mental and social problems afflicting veterans. The veteran must have access to comprehensive substance abuse services not only to deal with the symptoms, complex personal, family and social problems addiction causes, but also to be able to engage in treatment for these comorbid conditions. Engagement in state of the art PTSD treatment requires first or concomitantly treating a substance abuse problem in at least a third of patients presenting. Up to one half of veterans with serious mental illness also have a substance problem that complicates care.

There is growing concern with suicidality. Military studies are consistent with VA long term studies linking suicidal behavior to substance misuse for many, if not most.

Access to comprehensive substance disorder services is also crucial in providing care for non-mental health conditions that are a priority for veterans. For example, engagement in treatment for Hepatitis C requires abstinence, and continued heavy drinking has long term medical consequences. A common symptom in TBI is disinhibitory behavior, which is often manifest as substance misuse or its close cousin problem gambling. Again medical advice is for patients with TBI to stop drinking.

VA's priority mental health and medical programs cannot provide state of the art care unless they are complemented by comprehensive substance disorder use services.

What is the state of substance use disorder care in VA?

VA has been a leader in drafting evidence based treatment guidelines for substance use disorders. We know much about what works

In the past decade VA specialized access to substance abuse care has greatly eroded. Official VA reports document the decline. Much less is being spent on care. That could be attributed to increased efficiency, were it not for the fact that there has been a drastic decline in the unique number of veterans getting specialized substance abuse care. Nor is this due to lack of need. Three networks actually increased the number being served, while also becoming more cost efficient. The result is that today there are vast discrepancies in access to care across the country.

Very small improvements can be noted in the past two years as new money has been allocated to improve services. Even still, there are examples of medical centers taking expansion money for one mental health program while simultaneously cutting substance abuse services.

There are many dedicated staff working to provide care, but they are stretched and stressed. Many recognize that services need to be expanded and modernized to meet the needs of a new cohort of OIF/OEF veterans, but they have no resources to do so.

 VA programs often focus on the most severe dependent substance abusers. These patients need and deserve much care.

But the new veteran often needs a different kind of service. He or she may be at the beginning of the long drop; binge drinking, getting DUI's, starting to destroy family relationships. In the private sector you will find many comprehensive substance use disorder programs that include a hefty component to provide short term, tailored interventions for those at the hazardous or harmful phase of abuse. These brief intervention experts coordinate closely with primary care staff, educating them, working with them to assure that these patients get effective early care. Such programming is alarmingly rare in VA.

Military and VA studies document the growth of problem gambling. This is especially true for the new veteran. VA was a pioneer in gambling treatment. Yet today even few VA substance abuse programs systematically screen for this common comorbidity of substance use.

I could go on and provide more details but let me end here 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. A patriotic rural judge had let him off from his first DUI with a stiff warning. He wasn't the father or husband he always saw himself being. He'd had a rough deployment, but that wasn't what he wanted to talk about. I don't know if his problems were related to the trauma he witnessed or the explosion near him. He wanted to know what he should do. He wanted to do something, though there were many things he worried about in seeking help, including his career. I directed him to the VA nearest where he lived. It was not one I had visited recently. I hope he found ready immediate access to the services he needed at that VA, before he talked himself out of sticking with it.

Then and now, I am not sure he would.

The war is now. Men and women like him need the best we can offer in substance disorder services, now. We are, based on my ground level view, falling tragically short in meeting our responsibility to them.

I have many thoughts on what should be done. Let me share just one, though a big one.  VHA needs to immediately improve on the depth of the assessment I can provide. They must conduct a comprehensive comparison of each and every VA Medical Center and large outpatient clinic against VA's own practice guidelines for substance use disorders, including newer modern services for OIF/OEF veterans. This assessment should include site visits and confidential, non-attributional, discussion and surveys of substance abuse staff. A report detailing all short falls should then be used to deploy additional staffing to bridge some of the gap in services that has widened over the past ten years. It should not be local option whether a full array of services are provided. VHA is a national system, there should be a national predictable, consistent continuum of care so that any veteran can be assured of ready access regardless of where he or she resides.

I would rejoice if such a comprehensive assessment found that my ground level view was in error.

Addendum on problem gambling as a rising comorbity of substance abuse among veterans:

Scope of the problem:

Problem gambling is a serious problem that affects veterans and active duty service members and a common complicating comorbitity for other serious conditions. It has disastrous consequences for the veteran and his or her family.

Nationally between 1.6% and 3.4% of the general population have a lifetime probability of experiencing a significant gambling problem.  Rates among age matched veterans are significantly higher, and highest among minorities. Rates are even higher among veterans seeking treatment for some other condition. For example, studies have shown:

• A survey of veterans living in the community found that 9.9% of American Indian veterans and 4.3% of Hispanic veterans had a pathological gambling problem at some point in their lives.

• Up to one third of veterans in treatment for a substance abuse problem also have a significant gambling problem.

• Veterans in treatment for PTSD may be as much as 60 times more likely to have a gambling problem than age matched members of the general population

• Among veterans hospitalized on a VA inpatient psychiatric unit, 28% were classified as problem gamblers and 12% as pathological gamblers

Rates of depression among veterans with pathological gambling problems have been shown to be as high as 76%.  Suicide is extremely common, with 40% of veterans seeking treatment for gambling reporting suicide attempts.

There is every reason to believe that gambling will continue to be a problem for veterans.  Rates of gambling have been rising among active duty members, and of those seeking treatment for gambling, 42% have considered suicide.  This parallels increasing concern with financial troubles among military members and their families.

New studies have suggested that gambling may be an increasing problem for older patients being treated for neurological conditions such a Parkinson disease.  Rates of serious disorders of impulse control, mostly gambling, among patients receiving the most common pharmacological treatments (dopamine agonists) for Parkinson have been measured at 7%, well above the rate expected for age matched people in the general population.

A government commission estimated that the total costs (healthcare, legal, social) in the United States attributable to pathological gambling exceed $5 billion.

Availability of Treatment for Veterans with Gambling Problems

Specialized treatment programs for veterans with pathological gambling rare. Even though VA was the site of the first intensive national program for pathological gamblers, established forty years ago, and responsible for much of the early research on this disorder, the number of specialized programs in VHA is meager.

Despite overwhelming evidence that pathological gambling is a common and serious complicating comorbidity, veterans seeking mental health or substance abuse care in VHA are not generally screened for gambling problems.

There is substantial evidence that pathological gambling, even in its most serious form, can be successfully treated, including among veterans with the disorder. Rates of success continue to climb as newer treatment approaches are developed and studied. Economical screening instruments for gambling are available and have been shown to be effective in veteran populations.

Recommended Action

VHA should significantly increase access for veterans to specialized treatment for pathological gambling. Initially at least one program should be established in every VHA Network.

All veterans receiving VHA treatment for substance abuse, PTSD and other mental health conditions should routinely be screened for gambling problems, using available  standardized screening tools.

At least one staff member in every VHA substance abuse and PTSD specialized treatment program should be trained and competent in treating comorbid gambling problems.

VHA should establish a full-time position as national gambling coordinator within the office of the Mental Health Strategic Group. This person would be responsible for increasing access to treatment for veterans with gambling problems and assuring that veterans at risk for gambling problems are screened and referred to appropriate treatment when necessary.

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