American Psychiatric Association
On behalf of the American Psychiatric Association (APA), the medical specialty society representing over 35,000 psychiatric physicians and their patients nationwide, I welcome the opportunity to submit a statement for the record regarding the October 10th House Veterans Affairs’ Subcommittee on Health hearing, “Between Peril and Promise: Facing the Dangers of VA’s Skyrocketing Use of Prescription Painkiller’s to Treat Veterans.”
The APA has for several years stressed the need for funding and workforce strength to support comprehensive mental health and substance use disorder treatment in the Veterans’ Health Administration (VHA). The October 10th hearing highlighted a few issues which the APA has long advocated: improved prescription drug management programs (PDMPs) at the VHA as well as interoperability with state-run PDMPs, training of medical personnel on options for medically assisting substance use recovery, and the urgent need for non-opioid medications to treat chronic pain.
The focus of our statement is the veteran and returning military population, but issues such as medication diversion (taking a relative or friends’ medication), medication seeking (doctor-shopping), improper prescribing, inadequate informatics on prescription utilization, and the need for better pain management as well as utilizing medical options to assist with substance use disorders are prevalent for the United States population as a whole.
In 2008, Congress directed the VHA to develop and implement a comprehensive policy on the management of pain experienced by VHA patients. Many VHA facilities are making significant progress on implementing the VA’s mandate to improve pain management. In addition to this policy framework, VHA and Department of Defense (DoD) counterparts developed clinical practice guidelines for management of opioid therapy for chronic pain. The guidelines, first published in 2003, were intended to improve pain management, quality of life and quality of care. The guidelines were updated in May 2010 to reflect evidence-based practice. However, challenges still exist to fully implement evidence-based, comprehensive pain management as well as opioid addiction treatment.
Prescription Drug Management Plans (PDMPs)
Prescription Drug Management Plans help to identify and prevent potential misuse of prescription drugs, and assist in avoiding negative health outcomes for VA patients, including emergency treatment and accidental overdose. Thirty-eight states have PDMPs. Within the VHA itself, there is uneven utilization by providers of the VA’s own health records program to verify prescription data for patients.
The APA has expressed concern that barriers to quality patient care as well as a patient safety are the limitations in VHA’s ability to monitor prescriptions written for veterans outside of the VHA system. Prescription data coordination can assist VHA physicians in identifying veterans who need intervention and treatment for substance use disorders as well as prevent intentional overdosing by alerting physicians to multiple prescriptions. The APA is encouraged by the Interim Final Rule on the VHA’s prescription drug monitoring program effective on February 11, 2013, (VA-2013-VHA-0005-0001), which codified the VA’s PDMP. The APA looks forward to the VHA’s PDMP system’s interoperability with state-run PDMPs. We note, however, that there are no national standards for state PDMP information sharing and interoperability between states is a hurdle to overcome.
Therefore, the APA respectfully requests that the VA enhance its collaboration with the Department of Justice, Department of Health and Human Services and state Attorneys General to expedite interoperability of the VA PDMP with state PDMP programs using the prescription monitoring information exchange (PMIX) computer architecture.
Recruitment and Retention of Psychiatrists
VHA Deputy Undersecretary Robert Petzel, M.D., stated in January 2013 before the House Veterans’ Affairs Committee that the major workforce barrier to mental health and substance use treatment was the VHA’s difficulty in hiring and retaining psychiatric physicians. Congressional testimony given by current and former psychiatric physicians in the VHA highlights non-competitive pay, uneven training, and long hiring processes as key barriers to developing and maintaining a robust psychiatric workforce.
The APA strongly encourages the VHA to further adjust the pay tables for psychiatric physicians to more accurately reflect the acuity of VHA need as well as to redress the imbalance that occurs when newly hired psychiatrists have compensation packages that are not aligned with the compensation of career VHA psychiatrists with years of experience and training. Such redress may improve the retention issues at VHA.
Recruitment of psychiatrists as specialty physicians remains an issue at the VHA. According to USAjobs.gov on September 17, there were 142 federal job vacancies for psychiatrists listed, of which 138 were for the VHA; 128 positions were for permanent hires. Of the 128 vacant full-time positions, only 33 (25%) were even eligible for medical school loan repayment under the VHA’s Education Debt Reduction Programs (EDRP) program. Even if a VHA physician position is eligible for loan repayment, eligibility does not confer actual loan repayment. Under the EDRP program, a psychiatrist must apply for medical school loan forgiveness within six months of his or her hire date. VHA’s HR departments are all too often unaware of this six-month stipulation, rendering some psychiatrists ineligible.
The APA is developing a recruitment and retention workforce proposal for psychiatrists at the VHA that would establish a medical school loan forgiveness program similar to that provided by the U.S. Army. The proposal would be a time limited opportunity to increase the number of psychiatrists in the VHA and would also require a VHA study on its impact. We look forward to working with Congress to enact this and related proposals to increase the supply of psychiatrists providing care to our nation’s veterans.
Training the VHA Workforce: pain management and addiction treatment
Two issues overarch the VHA’s nationwide ability to meet its Congressional mandate to provide comprehensive pain management services to our nation’s veterans: evidence-based prescribing and pain management techniques for all veterans and enhanced availability of opioid-dependence treatment for those struggling with addiction.
The utilization of pain medication without benchmark pain assessments and accompanying treatment plan is inconsistent with good medical practice. Of particular concern is the prescription of multiple pain medications to veterans with multiple medical issues. Data suggest that some veterans with Post Traumatic Stress Disorder (PTSD) experience pain at a more intense level than their counterparts without PTSD. Veterans are subject to unique risk factors involving the misuse of prescribed controlled substances (Karen H. Seal et al., “Association of Mental Health Disorders With Prescription Opioids and High-Risk Opioid Use in US Veterans of Iraq and Afghanistan,” 307 JAMA 940 (2012)). Many veterans being treated for opioid dependence also have co-occurring diagnosis such as depression or anxiety. Treatment of these co-occurring illnesses only underscores the need for more psychiatrists in the VHA.
Academic detailing or enhanced pharmacologic training provided by physicians to VHA medical personnel regarding evidence-based for treatment of pain and opioid dependence is necessary throughout the VHA. Certain Veterans Integrated Service Networks (VISNs), such as VISN 20, 21 and 6 have implemented short, in-service training programs to change providers’ practices in prescribing pain medication, particularly for those patients with co-occurring PTSD and depression.
All too often, veterans (and other Americans) take prescription pain medication for orthopedic or nerve injuries and become addicted to or dependent on opioid medications used for pain. For opioid-addiction treatment options, the APA strongly encourages the utilization of and more trained physicians, particularly by psychiatrists who are specially trained, in the use Suboxone and Buprenorphine in opioid-dependence treatment. These medications act as ‘opioid antagonists’ and can assist in the supervised withdrawal from opioids. The APA is a partner organization in two clinical mentoring and education initiatives funded by the Substance Abuse and Mental Health Services Administration (SAMHSA): Physicians’ Clinical Support System-Buprenorphine (PCSS-B) and the Prescribers' Clinical Support System- Opioid Therapies (PCSS-O). Through the SAMHSA-funded grant, the APA has produced a series of webinars focused on the use of opioid therapies for treatment of opioid dependence and on the safe use of opioids in the treatment of chronic pain. The free webinars are available for psychiatrists, physicians of other specialties, other prescribers, residents, and other interested clinicians. Webinar recordings are available on this site. www.pcssb.org/educational-and-training-resources/special-topics and include:
- The Use of Buprenorphine to Treat Co-occurring Pain and Opioid Dependence in a Primary Care Setting
- Learning the Evidence Behind Alternative/Complementary Chronic Pain Management – Emphasis on Chronic Low Back Pain
- Patterns of Opioid Use, Misuse, and Abuse in the Military, VA, and US Population
- Enhancing Access to PDMPs Through Health Information Technology
- Identifying and Intervening With Problematic Medication Use Behaviors
- Assessing and Screening for Addiction in Chronic Pain Patients
- Psychological Management and Pharmacotherapy of Patients with Chronic Pain and Depression, Schizophrenia, and Post Traumatic Stress Disorder (PTSD)
Research on New Pain Medications
Federal agencies are currently involved in the development of new pain medications and methods to treat pain. The National Institute of Drug Abuse (NIDA) has been at the forefront of biomedical exploration. NIDA has, through an established testing program involving contract and grant mechanisms, developed several opiates pharmacotherapies that have been approved for use (Buprenorphine, Buprenorphine/Naloxone). Through interaction with leading substance abuse experts in academia, the pharmaceutical industry, and the Food and Drug Administration, NIDA has developed standardized outcome measures and success criteria for clinical pharmacotherapy trials, established clinical algorithms and standards for the conduct of exploratory clinical concept studies; human drug interaction studies; and Phase I, II, and III safety and efficacy studies. The Department of Defense, Veterans’ Administration and the National Science Foundation are other major federal agencies investigating new pain medications and treatment.
The APA has vigorously supported enhanced federal research to encourage the development of a new class of pain medications that would not have the same potentially addictive effects as long term use of opioids. Sustained, robust federal investment must be a national priority in order to make significant progress on inventing novel medications and developing new mechanisms – biological or chemical - to control pain. NIDA’s Clinical Trials Networks are currently testing on a few molecules of interest.
Pain management, addiction detection and effective treatment are significant priorities for our nation’s veterans. These objectives require the better coordination of opioid and benzodiazepine prescribing inside and outside the VHA. We strongly support robust research and more training throughout VHA medical personnel of the uses of medications such Suboxone and Buprenorphine to assist in the treatment of addiction, along with the development of new non-opioid medications to treat pain. Above all, we believe that access to a well-trained workforce grounded in the highest quality care and respect for veterans and their families is of paramount importance. We stand ready to assist you in achieving these goals.
The APA appreciates the opportunity afforded by Chairman Benishek and Representative Brownley to provide this statement on behalf of its members. Should you have any questions or need further information, please do not hesitate to contact my staff, Lizbet Boroughs, at (703) 907-7800 or firstname.lastname@example.org.
Saul Levin, M.D., M.P.A.
CEO and Medical Director
American Psychiatric Association