[House Hearing, 110 Congress]
[From the U.S. Government Publishing Office]




 
                  SUBSTANCE ABUSE /COMORBID DISORDERS:
                       COMPREHENSIVE SOLUTIONS TO
                           A COMPLEX PROBLEM

=======================================================================

                                HEARING

                               before the

                         SUBCOMMITTEE ON HEALTH

                                 of the

                     COMMITTEE ON VETERANS' AFFAIRS
                     U.S. HOUSE OF REPRESENTATIVES

                       ONE HUNDRED TENTH CONGRESS

                             SECOND SESSION

                               __________

                             MARCH 11, 2008

                               __________

                           Serial No. 110-75

                               __________

       Printed for the use of the Committee on Veterans' Affairs


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                     COMMITTEE ON VETERANS' AFFAIRS

                    BOB FILNER, California, Chairman

CORRINE BROWN, Florida               STEVE BUYER, Indiana, Ranking
VIC SNYDER, Arkansas                 CLIFF STEARNS, Florida
MICHAEL H. MICHAUD, Maine            JERRY MORAN, Kansas
STEPHANIE HERSETH SANDLIN, South     HENRY E. BROWN, Jr., South 
Dakota                               Carolina
HARRY E. MITCHELL, Arizona           JEFF MILLER, Florida
JOHN J. HALL, New York               JOHN BOOZMAN, Arkansas
PHIL HARE, Illinois                  GINNY BROWN-WAITE, Florida
MICHAEL F. DOYLE, Pennsylvania       MICHAEL R. TURNER, Ohio
SHELLEY BERKLEY, Nevada              BRIAN P. BILBRAY, California
JOHN T. SALAZAR, Colorado            DOUG LAMBORN, Colorado
CIRO D. RODRIGUEZ, Texas             GUS M. BILIRAKIS, Florida
JOE DONNELLY, Indiana                VERN BUCHANAN, Florida
JERRY McNERNEY, California           VACANT
ZACHARY T. SPACE, Ohio
TIMOTHY J. WALZ, Minnesota

                   Malcom A. Shorter, Staff Director

                                 ______

                         SUBCOMMITTEE ON HEALTH

                  MICHAEL H. MICHAUD, Maine, Chairman

CORRINE BROWN, Florida               JEFF MILLER, Florida, Ranking
VIC SNYDER, Arkansas                 CLIFF STEARNS, Florida
PHIL HARE, Illinois                  JERRY MORAN, Kansas
MICHAEL F. DOYLE, Pennsylvania       HENRY E. BROWN, Jr., South 
SHELLEY BERKLEY, Nevada              Carolina
JOHN T. SALAZAR, Colorado            VACANT

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
official version. Because electronic submissions are used to prepare 
both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.


                            C O N T E N T S

                               __________

                             March 11, 2008

                                                                   Page
Substance Abuse/Comorbid Disorders: Comprehensive Solutions to a 
  Complex Problem................................................     1

                           OPENING STATEMENTS

Chairman Michael H. Michaud......................................     1
    Prepared statement of Chairman Michaud.......................    42
Hon. Phil Hare...................................................     2
Hon. Shelley Berkley, prepared statement of......................    42
Hon. John T. Salazar, prepared statement of......................    43

                               WITNESSES

U.S. Department of Veterans Affairs, Antonette Zeiss, Ph.D., 
  Deputy Chief Consultant, Office of Mental Health Services, 
  Veterans Health Administration.................................    23
    Prepared statement of Dr. Zeiss..............................    59

                                 ______

Disabled American Veterans, Joy J. Ilem, Assistant National 
  Legislative Director...........................................    13
    Prepared statement of Ms. Ilem...............................    50
Iraq and Afghanistan Veterans of America, Todd Bowers, Director 
  of Government Affairs..........................................    17
    Prepared statement of Mr. Bowers.............................    58
McCormick, Richard A., Ph.D., Senior Scholar, Center for Health 
  Care Policy and Research, Case Western Reserve University, 
  Cleveland, OH..................................................     4
    Prepared statement of Dr. McCormick..........................    47
NAADAC, the Association for Addiction Professionals, Patricia M. 
  Greer, President...............................................     2
    Prepared statement of Ms. Greer..............................    43
Vietnam Veterans of America, Thomas J. Berger, Ph.D., Chair, 
  National PTSD and Substance Abuse Committee....................    15
    Prepared statement of Dr. Berger.............................    54

                       SUBMISSIONS FOR THE RECORD

American Legion, Joseph L. Wilson, Deputy Director, Veterans 
  Affairs and Rehabilitation Commission, statement...............    61
Miller, Hon. Jeff, Ranking Republican Member, and a 
  Representative in Congress from the State of Florida, statement    63


                  SUBSTANCE ABUSE /COMORBID DISORDERS:
                       COMPREHENSIVE SOLUTIONS TO
                           A COMPLEX PROBLEM

                              ----------                              


                        TUESDAY, MARCH 11, 2008

             U.S. House of Representatives,
                    Committee on Veterans' Affairs,
                                    Subcommittee on Health,
                                                    Washington, DC.

    The Subcommittee met, pursuant to notice, at 10:00 a.m., in 
Room 334, Cannon House Office Building, Hon. Michael H. Michaud 
[Chairman of the Subcommittee] presiding.

    Present: Representatives Michaud, Berkley, Hare, and 
Salazar.

             OPENING STATEMENT OF CHAIRMAN MICHAUD

    Mr. Michaud. I call the Subcommittee to order, and ask our 
first group of panelists to please come to the table.
    I would like to welcome everyone to our Subcommittee 
hearing today. We are here today to talk about treatment for 
substance abuse and comorbid conditions within the U.S. 
Department of Veterans Affairs (VA).
    Substance use disorders (SUDs) are among the most common 
diagnoses made by the Veterans Health Administration (VHA). 
According to the 2007 National Survey on Drug Use and Health, 
7.1 percent of veterans met the criteria in the past year for a 
substance use disorder. And 1.5 percent of veterans had a co-
occurring substance use disorder.
    Of the approximately 300,000 veterans from Operation 
Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) who 
have accessed VA healthcare, nearly 50,000 have been diagnosed 
with substance use disorder. Additionally, more than 70 percent 
of homeless veterans suffer from alcohol and drug abuse 
problems.
    Over the past several years, Congress has increased funding 
for substance use treatment programs within the Department of 
Veterans Affairs to $428 million in fiscal year 2008. I believe 
that continuing adequate funding is imperative for the health 
and well-being of our veterans and their families.
    Substance use frequently co-occurs with other mental health 
conditions. VA needs to continue to dedicate itself to 
providing services that can address both substance use and 
other mental health conditions such as post traumatic stress 
disorder (PTSD) simultaneously.
    I also was pleased to learn that Dr. Kussman, VA's Under 
Secretary for Health, recently released a directive on the 
management of substance use disorders. This directive states 
that, among other things, VA facilities must not deny care to 
any enrolled veteran because they are using substances. And 
that all VA medical facilities must provide services to meet 
the needs of veterans with substance use disorders and PTSD.
    I think that this is a step in the right direction. I 
commend VA for its proactive leadership on this.
    Last week, Mr. Miller and I introduced the ``Veterans 
Substance Use Disorder Prevention and Treatment Act of 2008.'' 
The Subcommittee realizes that substance use and comorbid 
conditions are complex issues. But we also recognize that it is 
important and that this deserves serious thought and 
consideration.
    I look forward to hearing from our panels today about the 
ways that the VA can effectively address these critical issues.
    [The prepared statement of Chairman Michaud appears on p. 42
.]
    Mr. Michaud. And now I would like to recognize Mr. Hare for 
an opening statement.

              OPENING STATEMENT OF HON. PHIL HARE

    Mr. Hare. I will be very brief. Thank you, Mr. Chairman. I 
want to thank you for holding this hearing and the continuance 
of hearings that you have organized about veterans mental 
healthcare.
    Substance use disorder and its comorbidity with post 
traumatic stress disorder are clearly a significant health 
issue among our returning veterans. And while it is crucial 
that we must understand what needs our veterans have, I believe 
that we must act quickly to ensure that the VA is providing the 
necessary services uniformly and across the Nation.
    And, again, Mr. Chairman, I thank you very much for this 
series of hearings. You do a wonderful job as Chairman of this 
Subcommittee, and I hope to have an informative hearing this 
morning. Thank you so much.
    Mr. Michaud. Thank you very much, Mr. Hare, for your 
leadership on veterans' issues as well.
    Our first panel is comprised of Patricia Greer, who is the 
President of NAADAC, the Association for Addiction 
Professionals; and Dr. Richard McCormick, who is a Senior 
Scholar from the Center for Health Care Policy and Research at 
Case Western Reserve University in Cleveland, Ohio.
    I would like to welcome both of you here this morning. And 
look forward to hearing your testimony. And we will start with 
Ms. Greer.

    STATEMENTS OF PATRICIA M. GREER, PRESIDENT, NAADAC, THE 
    ASSOCIATION FOR ADDICTION PROFESSIONALS; AND RICHARD A. 
McCORMICK, PH.D., SENIOR SCHOLAR, CENTER FOR HEALTH CARE POLICY 
  AND RESEARCH, CASE WESTERN RESERVE UNIVERSITY, CLEVELAND, OH

                 STATEMENT OF PATRICIA M. GREER

    Ms. Greer. Thank you, Mr. Chairman and Members of this 
Subcommittee, for holding today's hearings.
    The multiple challenges to our healthcare system to 
effectively treat co-occurring substance use disorders are 
significant. But experience has proven that there are practical 
steps, which will improve outcomes for clients and their 
families.
    I represent NAADAC, the Association for Addiction 
Professionals. We are the national professional association for 
addiction-focused health professionals and educators. NAADAC 
has 10,000 members across the United States and partner 
organizations in 46 States, two territories, and several 
foreign countries.
    I would like to take a minute to note the scope of the 
problem of substance use disorders and comorbidity. In 2004, 
Dr. Richard Suchinsky ranked substance use disorders as third 
in the list of diagnoses made by the VHA.
    However, reflecting a similar treatment gap in civilian 
society, substance use disorders remain under diagnosed and 
under treated in the VHA. In total, it is estimated that 1.8 
million veterans suffered from a diagnosable substance use 
disorder in 2002 and 2003.
    Substance use disorders often co-occur with other physical 
and mental health conditions. In the case of mental health 
conditions like PTSD, depression, or bipolar disorder, 
substance use disorders may develop from attempts to self-
medicate.
    Some experts estimate that about 40 percent of the veterans 
who have served in Iraq or Afghanistan will experience mental 
health problems. And of that number, approximately 60 percent 
will have a substance use disorder. National Guard forces 
report even higher rates of psychological distress than do the 
regular forces. And the stigma against addiction and treatment 
discourages many people from even seeking help.
    The Department of Veterans Affairs and Congress should be 
commended for having made mental healthcare for veterans a 
priority over the past several years.
    As this hearing's title suggests, co-occurring addiction 
and mental disorders are best treated comprehensively. 
Treatment for substance use disorders is most effective when 
delivered by trained healthcare professionals with either a 
certification or license in addiction-specific care. Licensure 
and certification ensures that the practitioner has both the 
education and the clinical experience in evidence-based 
practices to provide the best possible care.
    The 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. Reports that the addiction-focused VHA workforce has 
declined by almost half in the past decade are particularly 
disturbing.
    Simply stated, comprehensive care for co-occurring 
disorders requires professionals with knowledge of both the 
areas of addiction and mental health trauma.
    Additionally, several steps may be taken to enhance the 
comprehensiveness of care.
    First, early screening and intervention leads to more 
successful results. Of the veterans in the VHA system with 
diagnosable substance use disorders, only 19 percent received 
specialized addiction treatment. Primary care health 
practitioners must be trained in identifying substance use 
disorders and their co-occurring mental health conditions. And 
qualified addiction professionals should be on call to provide 
interventions when needed.
    Second, we believe that the VA should be accountable and 
transparent in cases where they do deny treatment to a veteran 
claiming to have combat-related symptoms or substance use 
disorders and report that information publically.
    Third, culturally competent care reflecting familiarity 
with military culture is essential for effective treatment. 
Fourth, the current conflicts require a new emphasis on gender-
specific treatment strategies. Servicewomen are closer to 
combat than ever before. Female veterans are more vulnerable to 
PTSD.
    The VHA should invest in studying gender-specific treatment 
and counseling strategies.
    Fifth, with the high rates of Reservists and National Guard 
forces in combat and extended tours of duty, families are under 
extreme stress. Post-deployment reintegration is often 
surprisingly difficult. Family inclusion in treatment programs 
are recommended whenever possible.
    Sixth, access to treatment should be as convenient and 
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 densely populated 
and less geographically dispersed than civilian treatment 
sites. This problem is particularly pronounced for veterans in 
rural areas.
    We encourage the Department of Veterans Affairs to 
aggressively pursue partnerships with existing civilian 
treatment centers. Strategic partnerships that expand the 
capacity of existing treatment systems in underserved areas 
would provide veterans and their families with timely care 
close to home, which is much more successful.
    In conclusion, the current conflicts in Iraq and 
Afghanistan pose many new challenges requiring a comprehensive 
plan of action.
    We would like to commend the Department of Veterans 
Affairs, this Subcommittee, and other policymakers who have 
worked to improve veterans' access to healthcare 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. I thank you for the opportunity to 
testify today. And I would also like to acknowledge the 
addictions treatment professionals in the room who are also 
veterans with us today. And I would be happy to answer any 
questions.
    [The prepared statement of Ms. Greer appears on p. 43.]
    Mr. Michaud. Thank you very much. Dr. McCormick?

            STATEMENT OF RICHARD A. McCORMICK, PH.D.

    Dr. McCormick. Mr. Chairman, Members of the Subcommittee, I 
will attempt in my limited remarks today to provide an 
independent, ground-level assessment of the needs of veterans 
for substance abuse disorder services and the current 
capability of VA to provide them.
    Let me first share the basis for my assessment. I retired a 
few years ago after 32 years in VA, where I worked clinically, 
mostly in substance abuse. Ending my career as the Mental 
Health Care Line Director for Network 10.
    I was Co-chair of the VA National Committee on the Care of 
Severely Mentally Ill Veterans, the mental health 
representative to the VA Central Office Task Force overseeing 
all practice guidelines, and Co-chair of the group drafting the 
practice guidelines for dually diagnosed veterans.
    After I retired, I had the additional opportunity to 
personally visit 39 VA facilities. First as a Commissioner on 
the VA Cares Commission, also as a member of a special 
Secretary's mental health task force, and then as a consultant 
on mental health and substance issues at a number of 
facilities.
    The last 2 years, I personally had the opportunity to visit 
23 military bases and Reserve units across the world as a 
member of the Department of Defense (DoD) Mental Health Task 
Force.
    On these visits, I talked to literally thousands of 
servicemembers, families, and providers about substance abuse 
and mental health issues.
    I continue to conduct National Institute on Alcohol Abuse 
and Alcoholism funded research at the university and am 
involved in two large Department of Defense follow-up studies 
on the mental health status of National Guard and Reserve 
members.
    First of all, the scope of the problem. The need for 
comprehensive substance use disorder services is immense and 
growing. Multiple studies show high rates of problems for 
returning War on Terror members.
    For example, among reservists who are veterans, weeks 
within their return, across studies looking at confidential 
surveys, it ranges from the 25 to 35 percent range on average 
for alcohol problems. When you look at the subset who have 
frequent deployments and high combat exposure, it goes as high 
as 52 percent.
    This hearing importantly focuses on comorbidities. 
Substance abuse is a common comorbidity for mental and social 
problems. The veteran must be able to access good substance 
abuse services to deal with other conditions as well. For 
example, most--all PTSD programs require that someone either 
concurrently or before they enter PTSD treatment deal with the 
substance abuse problem, which is a common comorbidity for up 
to one third of those going into treatment.
    There is growing concern with suicidality. A recent VA 
study of over 8,000 veterans in substance abuse treatment found 
that the year before they entered treatment, 9 percent had--
attempted suicide. The year after, 4 percent. The good news is 
there was a direct relationship to the amount of substance 
abuse treatment they got and the decrease in suicidal behavior.
    What is the--let me just say that VA's priority medical and 
mental health programs need a state-of-the-art substance abuse 
program to provide the care they need to provide.
    What is the state right now? VA has been a leader in 
establishing evidence-based guidelines for substance use 
disorders. We know what works. In the past decade, VA substance 
abuse care has greatly eroded. Official VA reports document the 
decline. Much less is being spent on the care. Two hundred 
million dollars less than was spent in fiscal year 1996.
    Some of that might be attributed to increased efficiency 
were it not for the fact there has also been a drastic decline 
in the number of unique veterans getting substance abuse care 
in VA. Nor is this due to lack of need. Three networks actually 
increased the care they provide, while increasing efficiency.
    But the result of this decline across the system, is that 
there is a vast discrepancy in access of a full--to a full 
continuum of care across the country.
    Small improvements can be noted in the past couple of years 
with new money. But even still, there are examples of medical 
centers that take expansion money for one thing and continue to 
reduce substance abuse services.
    There are many dedicated staff who provide care. Most VA 
programs do focus on the more severe, dependent abusers. But 
the new veteran often needs a new kind of service. He or she 
may be at the beginning of a long drop, binge drinking, getting 
caught driving under the influence (DUI), getting DUIs, 
starting to destroy family relationships.
    In the private sector, you will find examples, many 
examples, of comprehensive brief intervention initial treatment 
programs for such patients.
    Alarmingly, these are rare in VA. There are certainly 
examples of bright spots where it is happening. But across the 
system, they just aren't there.
    I could go on providing more details. But let me end 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. He wasn't the father or husband 
he always saw himself being. He had had a tough time in 
deployment, but he didn't want to talk about that. And he was 
reluctant even to go get some help with his alcohol problem.
    But he did want to do something. I directed him to the 
nearest VA facility nearest where he lived. It was not one I 
had visited recently. I hope he found ready, immediate access 
to services that he needed, before he talked himself out of 
sticking with it. Then and now, I am not sure he would.
    [The prepared statement of Mr. McCormick appears on p. 47.]
    Mr. Michaud. Thank you very much, Dr. McCormick.
    As you know, one of the issues that is important to me is 
access to veterans' healthcare for our veterans, all over the 
United States, but particularly in rural areas.
    What, Dr. McCormick, are some of the challenges in 
providing substance abuse treatment in rural areas? We heard 
Ms. Greer mention partnerships are one opportunity. Could you 
talk about the effectiveness of telephonic--or Internet-based 
treatment for substance use disorders?
    Dr. McCormick. Yes, thank you. One of the great strengths 
of VA, as you know, I am sure Mr. Chairman, is the 
establishment of community-based outpatient clinics (CBOCs), 
which are much more accessible, including especially to rural 
veterans than our medical centers generally.
    It is appropriate to have the most intensive substance 
abuse services at a medical center to a degree. But at every 
CBOC, every community-based outpatient clinic, in primary care, 
there needs to be someone who is expert in providing brief 
interventions to try to immediately impact, especially on those 
who are misusing rather than fully dependent, before they spend 
years going down that deep drop.
    And that isn't true right now. Even 4 years after people 
are coming back--and they need the services right when they 
come back to stop the drop. And that is true in rural. My own 
view is that the only way we will ever really attack the rural 
issue completely is for VA to contract some of that care in 
local communities.
    I myself believe VA can still be the provider of care and 
payer for care. But especially if it is an intensive outpatient 
program or even frequent outpatient visits, the reality is that 
if a veteran--I hear this many times. If a veteran has to drive 
100 miles both ways, with the price of gas today, that is not 
free care. That is real expensive care. It is true in Ohio. I 
am sure it is true in other rural areas, Florida as well.
    So that, yes, I think VA needs to bolster its programs, its 
intensive programs at the medical center. Make sure every CBOC 
can really provide immediate care. And I will say that there 
was a survey done. I was part of the group in 2004, VA's Health 
Services Research and Development Service (HSR&D) study, a 
survey of the leaders of primary care and ambulatory care in 
VA. The number one barrier they saw through their veterans--and 
they thought 29 percent of them had alcohol problems. The 
number one problem they had getting them to have short, brief 
treatment, was lack of resources.
    So VA can direct the care, pay for the care, but they will 
have to contract in some areas to make it truly accessible and 
useful.
    Mr. Michaud. What about Internet-based treatment? Do you 
think that is effective?
    Dr. McCormick. In terms of--you know, I really feel that 
the jury is out whether it is better to treat the disorders at 
the same treatment site or in separate treatment programs.
    But I would stress that the most important thing is that 
good care for mental health conditions and for medical 
conditions--take for example hepatitis C, you can't really--the 
effective treatments for hepatitis C requires someone--the need 
to be alcohol free. Likewise, even TBI, traumatic brain injury, 
one of the cardinal symptoms is disinhibition, often misuse of 
alcohol.
    And in fact, the current DoD advice for TBI patients is to 
abstain from alcohol. If somebody has TBI and has an alcohol 
problem, they need to be able to get those services.
    I myself think the jury is out whether they have to be done 
at the same time. We are still at the point of trying to make 
sure that every place we should have it, we have a robust, full 
continuum of care. So at least it can be offered concurrently.
    Mr. Michaud. Ms. Greer, would you want to answer that 
question about Internet-based treatment?
    Ms. Greer. My concern on Internet-based treatment is that 
one of the hallmarks of addiction is disconnection from your 
family, your friends, and your support network, your natural 
support network. So I find it difficult to endorse internet-
based treatment for addiction disorders.
    Mr. Michaud. Ms. Greer you recommend that the VHA should 
provide resources to its current healthcare workforce to become 
certified or licensed in addiction-specific treatment.
    How many VA health professionals are currently certified or 
licensed? What is the process you have to go through?
    Ms. Greer. Well, actually it varies from State to State at 
this point. All the armed services actually have a process, I 
believe, for certifying people that are interested in being 
certified addictions professionals. But it is not consistent 
nationally.
    Mr. Michaud. And with, mental health treatment, involvement 
of the family members is--I feel is extremely important. How do 
you both, Ms. Greer and Dr. McCormick, envision what that 
family involvement should look like? Do you feel that the VA 
currently promotes family involvement in substance use disorder 
treatment for our veterans?
    Dr. McCormick. Let me try that first. That is an excellent 
question. The reality is that there is less involvement of 
family actively in VA substance abuse programs than any 
comparable programs elsewhere in the community.
    Partly this is regulatory or at least staff belief about 
regulations. The reality is, especially for the new War on 
Terror veteran coming back, when you talk to National Guardsmen 
when survey--when we do surveys of them, marital problems are 
where things start to surface first, especially with repeated 
deployments.
    And yet, most VA medical centers don't make marital 
counseling readily accessible. It is available at Vet Centers. 
But, again, I would remind everyone that Vet Centers are much 
less accessible as an entity than our medical centers. And Vet 
Centers don't really do substance abuse care. So you are 
talking about trying to separate two things that should be 
separated, because the family, the wife--we are losing 
families.
    And because of losing families, we are losing veterans and 
servicemembers, including to suicide. It is the number one 
factor. You take these three things together: family problems, 
or relationship problems, or a ``dear John'' e-mail, alcohol 
and access to a weapon. That is what you see happening. That is 
why you see suicide. And that is why you see it so much.
    Mr. Michaud. Ms. Greer, do you want to add anything to 
that?
    Ms. Greer. I think that informing family members of the 
role that they play in post-deployment reintegration would be a 
key step in helping the adjustment to coming home, especially 
with marital difficulties.
    My concern is that speaking to professionals in Fort Hood, 
I understand their caseloads are in excess of 300, just with 
returning veterans themselves. And they are not able to handle 
the family connections that would go with treating the people 
they serve.
    So I don't know how it is nationally. But I know the local 
providers in Fort Hood are overwhelmed.
    Mr. Michaud. Thank you. And my last question, Dr. 
McCormick, since you formerly worked at the VA, we can provide 
all the resources that we think is needed in this particular 
area. But my concern is once that we do that, is to make sure 
that the resources get to the veterans that need it.
    I guess my question is how do you see that we as a 
Committee can make sure that the resources get where they are 
needed? What type of oversight do you think we need? Is there 
any report language that we should require the VA to report 
back?
    And the other issue is if we do not--if the veteran does 
not get the services that they need, what is that actual cost 
of that--to society as a whole? How much more expensive would 
it be since they are not getting the services that they need?
    Dr. McCormick. Two very important questions. Let me take 
the first one. You know, when I first came to VA, it was 
described to me as a series of fiefdoms. It changed somewhat, 
but not a lot.
    On the other hand, one of the things that has happened that 
is very good in VA, is the establishment of practice 
guidelines. Now the substance abuse guidelines need to be 
expanded with modern services on misuse for new veterans. Once 
that is done, my own belief is that a report card needs to be 
done on each and every medical center, comparing each and every 
medical center as to which parts of the continuum of care in 
VA's own evidence practice guidelines are readily available and 
accessible at that site.
    That report card should be used for two things. It ought to 
be made public, because frankly there are VA administrators at 
the local level who are recalcitrant about substance abuse 
services. But the light of day of a report like that gets 
converts that--and nothing else would get.
    Number two, it allows the money that you do give to go to 
the right places, because the bottom line is--as the Member 
correctly said earlier, the bottom line is to try to get 
accessible services across the whole system. So that if a 
veteran living in Ohio, who has a problem, gets the same access 
as one who lives in Florida. And the one in Ohio is probably 
depressed, because all the defeats we have had from Florida 
teams lately but beyond that.
    The second question you asked is also, you know, 
important--very important as well. And that has--but you have 
to remind me of it, because I am an old man.
    Mr. Michaud. Well, first of all, you mentioned having that 
report card.
    Dr. McCormick. Right.
    Mr. Michaud. Would you be willing to help to put together 
what that report card should look like? I think all too often 
what happens is once we pass legislation and it becomes law, 
that is it. There is really not much follow up.
    So I would like to make sure that, number one, that we have 
a report card that is legitimate and would really help us. And 
second, we can evaluate exactly what the Veterans Integrated 
Services Networks (VISNs) and VA are doing. So would you be 
able to help with the Committee staff?
    Dr. McCormick. Yeah. And there are many old VA people like 
myself who are around to do that. I would be glad to.
    I am still trying to remember the second important 
question.
    Mr. Michaud. The second question is when you look at taking 
care of our substance abuse, that has a cost to it.
    Dr. McCormick. Thank you.
    Mr. Michaud. But if we do not put that money up front, then 
there are other social costs that could be more expensive, 
including, unfortunately, loss of life because of suicide.
    Dr. McCormick. Well, yes. So first of all, there is--there 
are social costs, obviously, to the family and to the veteran 
himself. There are also medical costs, because untreated--
substance abuse treatment does work, although it is a chronic 
condition. And the earlier we intervene, the more likely we are 
to be successful down the road.
    The good news is the early interventions are our least 
expensive. So they save not only the veteran and his family all 
the psychological and social pain, they actually save money 
over time if we do them well.
    When substance abuse gets to be chronic, as somebody 
mentioned earlier, you get all kinds of things, including 
homelessness. Actually the number of patients in our homeless 
programs is more than 70 percent that have a substance abuse 
problem.
    And also there is a medical cost. Again, as I said earlier, 
and I just used two examples, I am on--we are doing a very 
large study on hepatitis C. If you aren't able to address 
substance abuse, it does really make it impossible to provide 
some state-of-the-art medical treatments, because alcohol--
excessive use of alcohol really keeps you from taking 
antivirals and many of the drugs that are most effective for 
that. So there is also a medical cost over time.
    Mr. Michaud. Thank you. Ms. Greer, did you want to add 
anything?
    Ms. Greer. I just wanted to add, that the Federal 
Government has studied this issue. I think it was around year 
2000, and it indicated that for every dollar we spend on 
intervention, prevention, early treatment, we save $7 down the 
road avoiding incarceration, the chronic deterioration by a 
chronic disease, and all the related societal costs.
    Mr. Michaud. That is a very good point. It would probably 
be worthwhile to get an up-to-date cost, since that is 8 years 
old.
    Ms. Greer. Well, I am sure they could help us?
    Mr. Michaud. Yes. Thank you. Mr. Hare?
    Mr. Hare. Thank you, Mr. Chairman. Ms. Greer, from your 
experience, is the treatment offered for SUD or addictions at 
the VA similar as far as programmatic aspects to those of the 
public sector?
    Ms. Greer. Unfortunately, I can't address that question. I 
haven't worked within the VA system. I only have secondhand 
reports.
    Mr. Hare. Okay. Dr. McCormick, would you?
    Dr. McCormick. They are for--if we are talking about 
programs for fully dependent patients, they are actually quite 
similar. The basis of them is really an intensive outpatient 
program with a residential option.
    A couple of things are different. There are few--there is 
less availability for methadone maintenance, which is 
actually--has a very heavy evidence base in VA than it is in 
the private sector. I also do consulting in the private sector.
    And the other one that I would, again, underscore, the--one 
of the huge differences that perhaps is most pertinent to the 
War on Terror is that VA programs are much less likely, in my 
personal experience, to offer early, short, brief interventions 
for people who are just starting down the slope.
    Our programs in VA tend, because of the kinds of patients 
we have treated over the years, to be kind of the end-of-the-
line programs. Now when I go around the Nation and you talk to 
VA substance abuse people, they recognize this. They would like 
to provide short, brief interventions. They just don't have the 
time. They are already barely floating.
    Mr. Hare. Well, Doctor, let me--you know, I know you worked 
in the VA system, as you mentioned, for several years and 
traveled all over the country. And let me first of all thank 
you for your service. It is a wonderful thing to do. But can 
you tell--maybe tell me how much of an understanding do you 
think the VHA professionals have about SUD? There seems to be a 
lot of stigma surrounding SUD and whether it is, you know, the 
willpower to stop, rather than a medical condition.
    And I guess my other part to that question is do you find 
this a problem in the VHA facilities? And would you agree with 
Ms. Greer's assessment that more specialized training for SUD 
need to be integrated into the VHA? It is a long question. I 
apologize.
    Dr. McCormick. No. Let me start. When you start at the 
ground up, if you talk to primary care doctors, having people 
come in for a 15, 20, most 30-minute visit, and as I said 
before, their own people say 29 percent of them have an alcohol 
problem. They recognize it is a problem. They recognize they 
have neither the time nor the training to address it.
    So they have to rely on the availability of other 
resources, particularly in the specialized substance abuse 
programs, which often are not really accessible for them or 
don't offer the kind of services their patients needed.
    As you go up the line, there are certainly many very 
enlightened VA clinicians and VA managers regarding the 
importance of substance abuse treatment. But there are many who 
are not. And this is one of the reasons that you have the 
undeniable variation. I mean, there is an order of three 
variation on the number of--the percentage of patients treated 
completely who get substance abuse care in the VA by network.
    So there is no question that that is a reality that, again, 
has to be overcome through top-down enforcement of a consistent 
continuum of care across the system.
    Mr. Hare. And lastly, I don't want to run out of time here, 
Mr. Chairman, but I just want to ask Ms. Greer one question. 
Just to clarify what the difference is, if any, between 
substance abuse disorder and an addiction?
    Ms. Greer. An addiction?
    Mr. Hare. Mm-hmm.
    Ms. Greer. You can have a substance abuse disorder that 
progresses to addiction. You may just have somebody that is in 
a phase of abusing substances. And that would be a substance 
abuse disorder. And that would be a warning that there is 
potential for dependency or addiction.
    Mr. Hare. I thank you very much. Thank you, Mr. Chairman.
    Mr. Michaud. Thank you. Ms. Berkley.
    Ms. Berkley. I thank you, Mr. Chairman. And thank you for 
holding this very important hearing.
    I would like to be able to submit my opening statement for 
the record, if I may.
    Mr. Michaud. Without objection.
    Ms. Berkley. Thank you.
    [The prepared statement of Congresswoman Berkley appears on 
p. 42.]
    Ms. Berkley. Thank you. Thank you both for being here to 
discuss with us a very important issue and to help educate us. 
And we always appreciate that.
    A constituent of mine, Lance Corporal Justin Bailey, 
returned from Iraq with PTSD. He developed a substance abuse 
disorder. And I know that they go hand in hand. He checked 
himself--with his family's insistence, checked himself into the 
LA VA facility in West Los Angeles. After being given five 
medications on a self-medication policy, Justin Bailey 
overdosed and died. His family, obviously, are beside 
themselves. And can't understand how he went in with a 
substance abuse problem, and was given more medication 
unsupervised.
    I have introduced the ``Mental Health Improvements Act,'' 
which aims to improve the treatment and services provided by 
the Department of Veterans Affairs to veterans with PTSD and 
substance abuse disorders.
    And what the legislation does is it expands substance abuse 
disorder treatment services at VA medical centers. It 
establishes national centers of excellence on PTSD and 
substance abuse disorders. It creates a program for enhanced 
treatment of substance use disorder and PTSD in veterans. It 
requires a report on residential mental healthcare facilities 
in the VA, creates a research program on comorbid PTSD and 
substance abuse disorders, and it expands assistance of mental 
health services for families of veterans.
    I think it is imperative that we provide adequate mental 
health services for those who have sacrificed for this Nation 
and those who continue to serve. Oftentimes these problems 
don't manifest themselves until quite a while after the 
service. But it is a serious issue. And we are recognizing it 
now, where I think in past wars, it existed. And we just chose 
not to recognize it.
    I am hoping that my colleagues, and I know there are only 
two here, will help cosponsor this and move it along. I think 
it is important and will help.
    But, Ms. Greer, I wanted to ask you. I am not sure. I mean, 
we are putting a lot of burden on our VA. In addition to the 
healthcare that our veterans require when they come home, and 
we will have several hundred thousand if not close to a million 
veterans from the current action and our resources are scarce. 
Added to the healthcare issues are also the mental health 
issues.
    And I am not sure--as a matter of fact I am quite convinced 
that we don't have enough people--doctors in the VA to 
accommodate the--what we are tasking them with, and will 
continue to task them with, and expand their task.
    Ms. Greer, do you think it would be beneficial to allow 
civilians to provide care to veterans with substance abuse 
disorders if they are qualified addiction specialists? Because 
right now our military people have to go through the VA.
    If we don't have enough personnel, and enough doctors, and 
enough addiction specialists to handle the influx of people 
that need their services, do you think it would be appropriate 
to reach out or go beyond the VA and certify addiction 
specialists that are not in the VA system to help treat these 
people?
    Ms. Greer. Well, absolutely. The establishment of 
professional standards is part of what our association does. So 
I can wholeheartedly recommend using certified addiction 
professionals or licensed addiction professionals, because they 
have got the training and the specific ability to be meaningful 
in their interventions with clients.
    Ms. Berkley. Thank you very much.
    Mr. Michaud. Thank you. Mr. Salazar? Well once again, Ms. 
Greer and Dr. McCormick, I want to thank you very much for your 
enlightening testimony. I appreciate you coming here today.
    Dr. McCormick. Thank you.
    Ms. Greer. Thank you, Mr. Chairman.
    Mr. Michaud. I now ask the second panel to come forward. 
Joy Ilem who represents the Disabled American Veterans (DAV); 
Doctor Thomas Berger who represents the Vietnam Veterans of 
America (VVA); and Todd Bowers who represents the Iraq and 
Afghanistan Veterans of America (IAVA).
    And I would like to thank the three of you for coming 
forward today to give your testimonies. And I would start off 
with Ms. Ilem.

   STATEMENTS OF JOY J. ILEM, ASSISTANT NATIONAL LEGISLATIVE 
DIRECTOR, DISABLED AMERICAN VETERANS; THOMAS J. BERGER, PH.D., 
  CHAIR, NATIONAL PTSD AND SUBSTANCE ABUSE COMMITTEE, VIETNAM 
 VETERANS OF AMERICA; AND TODD BOWERS, DIRECTOR OF GOVERNMENT 
       AFFAIRS, IRAQ AND AFGHANISTAN VETERANS OF AMERICA

                    STATEMENT OF JOY J. ILEM

    Ms. Ilem. Thank you, Mr. Chairman and Members of the 
Subcommittee.
    Thank you for inviting the Disabled American Veterans to 
testify at this important hearing on substance use and co-
existing mental health disorders in the veteran population.
    We owe our Nation's disabled veterans access to timely and 
appropriate care, including specialized treatment programs for 
those suffering with post-deployment mental health and 
substance use disorders.
    DAV has a growing concern about the reported psychological 
effects of combat deployments on veterans who have served in 
Iraq and Afghanistan. There is converging evidence that 
substance use among other post-deployment mental health 
problems is a significant problem challenge for many of these 
veterans. And that the incidence of this problem will likely 
continue to rise if not properly addressed.
    At one facility, VA researchers examined substance abuse 
and mental health problems in returning Iraq veterans and 
concluded that increasing attention is being paid to combat 
stress disorders but that there was insufficient systemic focus 
on the substance abuse problems in this population.
    Access to substance abuse services for the group studied 
was very low, only 9 percent, compared with access to other 
mental health services, reported at 41 percent.
    In my written statement, I also cite a number of other 
studies that illustrate the apparent nature and scope of this 
problem.
    Unfortunately, over the past decade, VA substance abuse 
rehabilitation services have declined and VA has made little 
progress in restoring them, even in the face of higher demand 
from the newest generation of combat veterans.
    Although it is well known that many mental health 
conditions, including PTSD, anxiety disorders and depression 
are frequently associated with substance misuse, VA is not 
sufficiently focused on restoring these specialized services, 
including integrated treatment programs to address these co-
existing disorders.
    We are also concerned about the market increase in 
geographic variability of access to comprehensive substance 
abuse services noted across the VA system, as well as reported 
inconsistencies in offering inpatient detoxification services.
    We hope VA will set in place clear policies to ensure that 
a comprehensive set of substance abuse disorder services are 
available and consistently provided to all veterans who need 
them. These services should include 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; 
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.
    While we applaud VA's efforts to save individuals from the 
misery of chronic addiction, we note that VA has traditionally 
limited its program focus on those who have seemingly hit rock 
bottom. Experts agree that early interventions for substance 
use are more successful when they have not been allowed to 
become compounded or chronic.
    Therefore, we believe access to a robust array of substance 
abuse disorder services and an expanded focus on prevention and 
early intervention is not only warranted, but critical to our 
newest generation of war veterans suffering with post-
deployment readjustment issues.
    Lack of access to such services could result in sub-optimal 
rehabilitation for thousands of veterans, including many with 
comorbid medical and mental health conditions that require 
concurrent retreatment of their alcohol and/or substance use 
disorders.
    With these views in mind, DAV recommends the Subcommittee 
advance legislation that assures a full continuum of substance 
use disorders care for veterans who need it, along with an 
annual update to Congress on VA's progress in providing such 
services.
    We also urge authorization of a pilot program, specifically 
designed to offer web-based options for VA substance use 
counseling, treatment, and group support targeted at rural 
veterans.
    And finally designated funding for research projects to 
identify best treatment strategies to collectively address 
substance use disorders and other comorbid mental health 
readjustment problems.
    Congress and VA must ensure that Federal programs aimed at 
meeting the unique post-deployment needs of veterans are 
sufficiently funded and adapted to meet them, while continuing 
to address the chronic health maintenance needs of previous 
generations of disabled veterans.
    Additionally, Congress should require VA to report on how 
it is spending the significant new funds that have been added 
and earmarked for the purpose of meeting post-deployment mental 
healthcare and physical rehabilitation needs of Operation Iraqi 
Freedom/Operation Enduring Freedom (OIF/OEF) veterans.
    In closing, VA needs to have effective programs in place 
now aimed at prevention and early intervention, outreach and 
education, as well as training for veterans and their families 
to close the current gaps that exist.
    We deeply appreciate the Subcommittee's interest in these 
issues. And we want to thank the Chairman and Ranking Member 
for jointly introducing the ``Veterans Substance Use Disorders 
Prevention and Treatment Act of 2008,'' a measure that would 
accomplish many of the goals that we have mentioned today.
    Mr. Chairman, that concludes my statement. Thank you.
    [The prepared statement of Ms. Ilem appears on p. 50.]
    Mr. Michaud. Thank you. Doctor.

              STATEMENT OF THOMAS J. BERGER, PH.D.

    Dr. Berger. Vietnam Veterans of America thanks you for the 
opportunity to present our views on substance abuse and 
comorbid disorders.
    As you are well aware, substance abuse and PTSD form one of 
the pillars for my organization. And after 30 years in 
existence, still represent a very important component of our 
legislative agenda.
    Foremost VVA thanks you for your leadership in holding this 
hearing today on a most serious concern within the veterans' 
community, because each month hundreds of active-duty troops, 
Reservists and National Guard members return to their families 
and communities from deployment in Iraq and Afghanistan.
    Given the demanding and traumatizing environments of their 
combat experiences, many veterans experience psychological 
stresses that are further complicated by substance use and 
related disorders. In fact, research studies, as we have 
already heard this morning, indicate that veterans in the 
general U.S. population are at increased risk of suicide.
    I was greatly heartened to hear the Chairman refer to the 
National Survey on Drug Use and Health Reports. I am not going 
to spend any time going over those figures, since they have 
already been mentioned.
    But we must remember that those data that the Chairman 
presented to us today, only those veterans who chose to seek 
help for their disorders from the VA are the ones that are 
mentioned.
    VVA has no reason to believe that the numbers cited in that 
report would not be higher if more of our OEF and OIF veterans 
were to seek VA care.
    I should also like to point out that yesterday an article 
appeared in the ``Stars and Stripes,'' just briefly. It was the 
results of the Defense Department's health behavior survey, 
which indicated amongst young sailors, airmen, especially 
Marines and soldiers, 18.5 percent overall indicated on the 
questionnaire that they would be put in the category of heavy 
drinking. The Army's actual rate was higher, 24.5 percent. So 
the numbers we heard mentioned by the Chairman earlier, I 
submit, may be actually higher.
    The medical, social, and psychological toll from substance 
abuse disorders is enormous, both for the military and the 
civilian sectors. In the face of such overwhelming damage, two 
questions come to my mind: Why does substance abuse receive 
relatively little medical and public health attention and 
support compared with other medical conditions? And what can be 
done to reduce the harm from substance abuse disorders?
    Despite their huge toll, substance abuse disorders remain 
underappreciated and underfunded. And reasons for this include, 
in my opinion, stigma, tolerance of personal choices, 
acceptance of youthful experimentation, pessimism about 
treatment efficacy, fragmented and weak leadership, powerful 
tobacco and alcohol industries, underinvestment in research, 
and difficult patients.
    Now I am not going to spend a lot of time going over all of 
those, but despite those obstacles, VVA believes that a 
coordinated, workable agenda within both the military and 
civilian sectors is possible to lessen the impact of substance 
use disorders.
    But this better approaches for treatment. For example, 
adequate treatment for substance abuse is particularly 
challenging for America's uninsured. Even for the insured, many 
policies, including most Medicaid programs, do not cover the 
time for counseling or the costs of drugs for substance use 
disorders. Again, as new, effective drugs come on the market, 
patients must have access to them.
    We need to devote more support for research. Increase the 
percentage of the current National Institutes of Health (NIH) 
budget to substance abuse research. For example, beyond 
studying the basic science of addiction and exploring new 
pharmacologic treatments, research could help us better 
understand why some people who experiment with substances 
become addicted while others do not.
    There needs to be better education of health professionals. 
Substance abuse receives minimal notice in undergraduate and 
graduate medical school curricula, especially board certifying 
exams, continuing medical school education, standard clinical 
textbooks, and medical journals.
    There needs to be stronger leadership. Greater recognition 
of substance abuse and substance abuse disorders as a major 
health program or problem should encourage broader and more 
diverse leadership.
    We also need to provide adequate treatment for community-
based and incarcerated people with drug addiction, because it 
generates social and medical savings, lower crime, lower prison 
spending, less family dysfunction, and better health.
    A RAND report of mandatory minimum sentences for cocaine 
concluded that dollar for dollar, treatment is fifteen times 
more effective than incarceration in reducing serious crime.
    We also need to reform the criminal justice system for 
substance abuse. Federal and State legislation imposes 
mandatory terms for possession of illicit drugs, thereby 
removing sentencing discretion from the hands of judges. Drug 
courts are an effective antidote to this.
    Substance abuse remains a serious medical, public health, 
and social problem in both our civilian and military sectors. 
Yet it lacks champions, is underfunded, and is relatively 
neglected by clinicians and the medical establishment.
    Despite some real progress in the past decade, the United 
States still lags behind virtually every developed country in 
measures of health status. Our current national strategy to 
close that gap involves funding for biomedical research to 
yield new treatments and improving access to care for everyone, 
including America's veterans.
    That concludes my testimony. Thank you very much.
    [The prepared statement of Dr. Berger appears on p. 54.]
    Mr. Michaud. Thank you, Doctor. Mr. Bowers?

                    STATEMENT OF TODD BOWERS

    Mr. Bowers. Mr. Chairman, Ranking Member, and distinguished 
Members of the Subcommittee, on behalf of the Iraq and 
Afghanistan Veterans of America, and our tens of thousands of 
members nationwide, I thank you for the opportunity to testify 
this morning regarding veterans' substance abuse.
    I would like to make it very clear also that I am here 
testifying in my civilian capacity as the Director of 
Government Affairs and my opinions and views today in no way 
reflect the Marine Corps, which I currently serve as a sergeant 
in the Reserves.
    I would like thank the Committee for recognizing the issue 
of comorbidity. As the Committee knows, among the hundreds of 
thousands of troops returning from Iraq and Afghanistan with a 
mental health injury, a small but significant percentage is 
turning to alcohol and drugs in an effort to self-medicate. 
Veterans' substance abuse problems, therefore, cannot and 
should not be viewed distinct from mental health problems.
    According to the VA Special Committee on post traumatic 
stress disorder, at least 30 to 40 percent of Iraq veterans, or 
about half a million people, will face a serious psychological 
injury, including depression, anxiety, or PTSD. Data from the 
military's own Mental Health Advisory Team shows that multiple 
tours and inadequate time at home between deployments increase 
rates of combat stress by approximately 50 percent.
    We are already seeing the impact of these untreated mental 
health problems. Between 2005 and 2006, the Army saw an almost 
threefold increase in ``alcohol-related incidents,'' according 
to the DoD Task Force on Mental Health.
    The VA has reported diagnosing more than 48,000 Iraq and 
Afghanistan veterans with a drug abuse problem. That is 16 
percent of all Iraq and Afghanistan veteran patients at the VA. 
These numbers are only the tip of the iceberg. Many veterans do 
not turn to the VA for help coping with substance abuse, 
instead relying on private programs or avoiding treatment 
altogether.
    Effective diagnosis and treatment of substance abuse is a 
key component of IAVA's 2008 legislative agenda. First and 
foremost, IAVA supports mandatory and confidential mental 
health screening by a mental health professional for all 
troops, both before and at least 90 days after a combat tour. 
Moreover, the VA must be authorized to bolster their mental 
health workforce in hospitals, clinics, and Vet Centers with 
adequate psychiatrists, psychologists and social workers to 
meet the demands of returning Iraq and Afghanistan veterans.
    At this point, I am going to separate from my written 
testimony and try and share with the Committee an experience I 
had a week before last at my Marine Corps Reserve Center. We 
all have heard about the post-deployment health reassessment 
(PDHRA) survey. This is a form that individuals are required to 
fill out when they return. We filled this out the weekend 
before last. And I wanted to highlight a few of the questions 
that are actually on here.
    On section 10, question A and B, we have, ``In the past 
month, did you use alcohol more than you meant to? Yes or no. 
In the past month, have you felt that you wanted to or needed 
to cut down on your drinking? Yes or no.'' And at the bottom 
there is still an element of self diagnosis for whether you 
would like follow-up treatment, which is, ``Are you currently 
interested in receiving information or assistance for a stress, 
emotional or alcohol concern?''
    Now I have to say that filling this form out was incredibly 
useful for our Reserve Center. It allowed people to fill this 
out confidentially and then sit down with a counselor that 
would review the PDHRA and recommend whether individuals needed 
to go see a mental health professional or a follow-up 
appointment.
    The important aspect of this was that we were allowed a 
confidential referral notice. When we filled out the paperwork, 
if we did want a follow-up appointment, it was kept completely 
confidential. From that point, we moved over and the Veterans 
Administration was at our Reserve Center to enroll every single 
person who had just completed the PDHRA or who had deployed for 
over a 90-day period with the Veterans Administration. They 
provided us a tremendous amount of pamphlets. I have four here 
approximately, each stating that they have resources available 
for substance abuse problems.
    At that point we then contact--we were connected with our 
local Vet Center. We spoke with individuals from Maryland, 
Washington, DC, and Virginia, because we are stationed here in 
Washington. And they put us in touch with the right sources.
    To sum it up, it was perfect. It is exactly what needs to 
be done for a seamless transition for individuals in the 
National Guard, Reserves, and also active duty to transition to 
the VA.
    The problem was, it was one corpsman at my unit who 
organized this. It is not mandated across the board for 
individuals to have the same sort of screening process and 
information sessions on what resources are available and, more 
importantly, communication for these individuals. It was just 
our unit being proactive.
    So I would like, if anything is taken away from my 
testimony today, that we see that there needs to be that 
communication of resources directly with the National Guard 
units and Reserve units for Iraq and Afghanistan veterans to 
know what resources are made available.
    I have been home from my last deployment to Iraq for almost 
3 years now. And we are just now getting it right. They are 
just now doing it. But it is not across the board. If we do the 
same type of screening that we have done for my unit, for every 
Reserve Center, again, we can keep people from falling through 
the cracks.
    And I welcome any questions at this point. Thank you.
    [The prepared statement of Mr. Bowers appears on p. 58.]
    Mr. Michaud. Thank you very much, Mr. Bowers. That was very 
enlightening. And I really appreciate it, because actually that 
is where a lot of my questions were going.
    As with any behavioral conditions, early interventions for 
substance abuse disorders, effective screening is extremely 
important.
    I guess I would ask the other two how--you heard Mr. Bowers 
mention what he thought was very helpful. How would you assess 
the VA's substance abuse screening protocol, and what 
suggestions would you have about the VA and the DoD? How can 
they work together to provide outreach for returning veterans 
for OEF and OIF or veterans in general?
    Dr. Berger. Mr. Chairman, I will just jump in right here. I 
think what Mr. Bowers said is very, very appropriate. But as he 
said, it took him 3 years to get to this point. So what can we 
do to make sure that it permeates the system for our returning 
vets?
    Mr. Michaud. Is there anything that Mr. Bowers did not say 
or any additional ways that the VA or DoD might be able to 
further this along?
    Dr. Berger. I would just like to note that I was a Navy 
corpsman. And I have served as a Navy corpsman with the Marines 
in Vietnam.
    Mr. Michaud. Great. Ms. Ilem, do you have any----
    Ms. Ilem. I think you mentioned at the opening of the 
hearing about VA indicating that they are--they have sent out 
memorandum or whatever making sure that substance abuse 
services are available throughout--comprehensive services 
throughout the system. And I think, you know, that will take 
oversight on their behalf to make sure then, really at the 
local levels, that that is happening.
    I know that the Vet Centers have testified before that they 
have been actively going out. And certainly their reports 
reflect that in terms of providing support for these returning 
troops in the Guard and Reserve.
    It would be interesting to, you know, continue to see the 
number of folks that they are really assisting. And if they 
are, you know, taking it--doing this type of a program. And 
making sure that that is consistently available in their Vet 
Centers throughout the country.
    Mr. Michaud. Great.
    Dr. Berger. Mr. Chairman, if I might add one thing. I 
participate in the Transitional Assistance Program in the State 
of Missouri.
    The brochures and handouts that Mr. Bowers mentioned, that 
would be appropriate to hand out at these kinds of meetings. 
And I know that our returning troops get exposed to a lot of 
paperwork and a lot of information at these transition 
assistance program meetings.
    But the fact of the matter is, that the materials on 
substance abuse and PTSD need to be bumped up toward the top of 
the list, because that is what is affecting these folks.
    Mr. Michaud. Mr. Bowers, do you have anything else you want 
to add to that?
    Mr. Bowers. Just real quickly if I could, Mr. Chairman. One 
of the things that we have highlighted is that the Vet Centers, 
though they are an outstanding resource, are extremely 
understaffed right now. And that is something that when I spoke 
to individuals at the Vet Centers, they said we are just--we 
are getting beat up right now. And they do need some help in 
staffing shortages.
    Mr. Michaud. Thank you. Doctor, you had mentioned research 
at NIH, and research is very important. Are there any specific 
areas of research or research questions relating to substance 
abuse or comorbid disorders that you think the VA should focus 
on?
    Dr. Berger. As I hinted at, Mr. Chairman, research 
questions that focus on helping us understand why people who--
some people who experiment with substance become addicted, 
while others do not.
    The area of resiliency--the comparative efficacy, excuse 
me, of different modes of treatment, because you know there is 
some conflict in certain circles amongst pharmacological versus 
psychological treatment or the 12-step program treatments.
    The complexities of dual diagnosis, that is the co-
occurring mental illnesses and substance abuse, the social 
context of addiction, as you yourself know from the information 
you gave us this morning, that individuals who are in lower 
income areas, that is less than $20,000 on that national drug 
survey, seemed to be--are at higher risk for substance use 
disorders. And, obviously, the impact of our various social 
policies on addiction and the harm it causes.
    Those are all questions that could be turned into 
significant research components in my estimation.
    Mr. Michaud. Thank you. My last question is it is my 
understanding from talking to a veteran last week, a member of 
the Veterans of Foreign Wars (VFW) of the United States, the 
Deputy Secretary of the VA and the Surgeon General were talking 
to the VFW and mentioned PTSD-NR. It was the first time I ever 
heard it, the new classification of PTSD-NR. I assume the NR is 
probably normal reaction. I am not sure.
    Have any of you heard of that new classification?
    Have any of your members brought it forward? And I'll ask 
this of the VA when they come up, what the NR is for.
    Dr. Berger. I will just add, I have not heard about that 
specifically. But one takeaway I did gather from my Marines 
this weekend was that they said, if there are no problems with 
it, why is it still referred to as a disorder. Everybody kept 
pushing whether it was Army's Battle Mind training or things 
along those lines saying that, there is nothing wrong with it, 
but it is still a disorder and until that name change comes, 
until that national stigma is reduced about mental health 
issues, which whether it be a combat mental injury, whatever 
name people decide to give it, we are going to have a really 
hard time getting folks to step up and get the treatment that 
they need.
    Dr. McCormick. I have not heard of any either, sir.
    Mr. Michaud. Okay. Thank you. Ms. Berkley?
    Ms. Berkley. Thank you Mr. Chairman. Thank you all very 
much for outstanding presentations. Actually all of our 
presenters have been quite informative.
    Just an observation, I guess, and then a question at the 
end.
    I spend a considerable amount of time with my veterans in 
the Las Vegas Valley in Southern Nevada, and of course we have 
got the fastest growing veterans population in United States 
there.
     On the 4th of July in addition to other times that I 
interact with my homeless vets, on 4th of July, I go to the 
United States Vets Home for the homeless and get on the buffet 
line and serve our veterans, and it occurs to me, when I am 
standing there serving, that they are mostly Vietnam Vets, 
which is my age group and my war, for lack of a better word. I 
was very comfortably serving at the University of Nevada when 
these men, mostly, were in Vietnam.
    It always strikes me when I sit down and talk with my 
Vietnam Vets who are homeless, and have some major issues. What 
I am struck with, is we have normal conversations all the time 
and they are quite intelligent and if not for the grace of God, 
go I, but I'm wondering if we have any statistics that you can 
share with us on the comorbid substance use disorders for 
Vietnam Vets. Is it particularly prevalent? Is it just that we 
ignored it at the time? What information can you give me? And I 
know that with each war we have our own set of issues with our 
veterans, many similar, but many unique to that particular war. 
But I know my Vietnam Vets had a very, very tough way to go 
when they came home. And here we are many years later and they 
are, you know, still suffering from the experience.
    Dr. Berger. That is a very good question, ma'am. Amongst my 
generation with everything that was going on at the time. World 
War II and Korea Vets came home and drank a few beers. It was a 
good time. We won.
    Ms. Berkley. Yeah.
    Dr. Berger. Vietnam, there were lots of things going on 
within our culture, and our drug of choice was marijuana for 
the most part. And while we are not proud of that, that is what 
happened.
    We were also disenfranchised. And I think particularly when 
we're talking about my cohort of veterans, all these things 
came together, unfortunately, and that is why you will 
occasionally run into vets, as you said, at these festivals or 
celebrations from Vietnam.
    Ms. Berkley. Do we have any statistics regarding substance 
abuse for our Vietnam Vets?
    Dr. Berger. I will have to ask my colleagues from the VA.
    Ms. Berkley. Okay, just curious about that. And let me ask 
you, I asked the question to Ms. Greer in the earlier panel, do 
you feel in the least bit uncomfortable with having civilians 
that have specialties in addiction services counsel?
    Dr. Berger. I have no problem with it on one hand however; 
as I mentioned a couple of weeks ago while testifying on mental 
health related issues, I think it is important when you are 
talking about the use of nonmilitary trained people, that there 
is an element of trust.
    Ms. Berkley. Yes.
    Dr. Berger. Okay. That has to be overcome and I don't care 
whether we are talking about mental health professionals or 
substance abuse professionals. Trust is very important when it 
comes to dealing with our Nation's military when it comes to 
these particular disorders we are talking about.
    So with caveat in mind, no, I do not have a problem with 
it.
    Ms. Berkley. Okay. Anybody else care to comment?
    I am just concerned about the lack of resources in the VA 
and personnel that can treat the numbers of people coming back 
with substance abuse disorders and PTSD. And I know, look my 
dad is a World War II Vet, he would not go anyplace else for 
his healthcare than the VA. I mean, there is a camaraderie, 
there is a comfort level.
    And I know that there are thousands of my World War II Vets 
in Vegas that they could easily go to another place for their 
healthcare, they want to go to the VA. They like going there. 
They like seeing their friends. They like the comfort level 
there, and I don't think that should be denied. But there ought 
to be some way that we can get civilians that may have served 
that can relate to our returning veterans that have PTSD and 
substance abuse problems that aren't necessarily working for 
the VA.
    Dr. Berger. I think there are ways particularly to take 
advantage, as was mentioned a couple of weeks ago before this 
very Committee, to take advantage of peer counseling programs 
when it comes to substance abuse. I know if that would have 
been available for Vietnam Veterans there would be a lot fewer 
Vietnam Veterans with substance abuse issues today.
    Ms. Berkley. Thank you, very much.
    Mr. Michaud. Just one last question, doctor. You had 
mentioned incarceration as I said earlier. If you don't take 
care of the problem up front, we have a long cost, at the other 
end.
    Dr. Berger. That's correct.
    Mr. Michaud. Have there ever been any studies done about 
veterans who might have been incarcerated for alcoholism or 
drug abuse, because that actually shifts the burdens on to the 
State and the county jails and what have you. Do you know if 
there have ever been any studies done on that?
    Dr. Berger. There have been a couple of studies that many 
of the folks behind the walls do have substance abuse problems. 
I wish I could just find it here in all the information I 
brought along today. I am one of those who tend to bring more 
ammunition than I actually need.
    Mr. Michaud. Well, if you could just provide it to the 
Subcommittee.
    Dr. Berger. Well it is in my testimony, sir, where I hint 
at it. But it is a problem within the penal system, substance 
abuse disorders.
    Mr. Michaud. Because I do know that also, that is not the 
only cost of keeping someone incarcerated, but also if the 
county has to take up the cost of providing the healthcare, 
versus the VA, that's an added cost at the State level that 
really concerns me.
    So I would like to, if there has not been an up-to-date 
study on that, I would be very interested in making sure we get 
one because that is a shift that should not occur.
    Dr. Berger. Okay. One thing, if I may mention, sir. Vietnam 
Veterans of America is very proud of the fact that we have 
chapters inside the walls at many of our institutions and no 
other veterans service organization can make that claim.
    Mr. Michaud. Thank you. Once again I want to thank this 
panel for your testimony this morning and look forward to 
working with you as we move forward with this piece of 
legislation. I thank each of you very much.
    Our last panel is Dr. Antonette Zeiss, who is the Deputy 
Chief Consultant for the Office of Mental Health Services 
within the VHA, accompanied by Charles Flora, the Associate 
Director of Readjustment Counseling Service, and Dr. John Paul 
Allen, the Associate Chief Consultant for Addictive Disorders.
    I would like to welcome the doctor, and the other two that 
are accompanying you today and look forward to hearing your 
testimony as well.

 STATEMENT OF ANTONETTE ZEISS, PH.D., DEPUTY CHIEF CONSULTANT, 
       OFFICE OF MENTAL HEALTH SERVICES, VETERANS HEALTH 
     ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS; 
     ACCOMPANIED BY CHARLES M. FLORA, ASSOCIATE DIRECTOR, 
       READJUSTMENT COUNSELING SERVICE, VETERANS HEALTH 
 ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS; AND JOHN 
  PAUL ALLEN, PH.D., ASSOCIATE CHIEF CONSULTANT FOR ADDICTIVE 
 DISORDERS, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF 
                        VETERANS AFFAIRS

    Dr. Zeiss. Thank you very much for having us here at this 
very, very important hearing. Like the other panelists we share 
the sense that this is really tremendously important, and we're 
very glad to be able to talk about what the VA is doing and to 
answer your questions.
    I am pleased to be here today to discuss those ongoing 
steps that the VA is taking to treat substance use disorder and 
comorbid disorders.
    I am accompanied by Mr. Charles Flora who is the Associate 
Director of Readjustment Counseling Service. He is a clinical 
social worker and Vietnam veteran, and has a lifetime of 
experience in readjustment counseling at both the Vet Center 
and national levels.
    I am also accompanied by my colleague and my new friend, 
Dr. John Allen, Associate Chief Consultant for Addictive 
Disorders in the Office of Mental Health Services.
    Dr. Allen is a national expert on substance use disorders 
and he is a veteran of Operation Iraqi Freedom.
    The VA has always taken the problem of substance use 
disorder very seriously and has demonstrated our commitment to 
helping our veterans overcome this disease and we welcome Dr. 
Allen's personal connection to our returning veterans as well 
as his expertise in this area.
    We thank the Committee and you, Chairman Michaud, for your 
active interest in this topic. Tragically, substance use 
disorders are common in our society, as you have been hearing 
daily and are definitely common as they are in many societies. 
And the incidence of substance use among veterans tends to 
exceed that of comparable civilian populations. For example one 
study by Todd Wagner, in 2007, found that veterans are more 
likely than non-veterans to report driving under the influence 
of alcohol, smoking daily, and using marijuana. In another 
study, Dr. Charles Hoge published in the New England Journal of 
Medicine in 2004 showing that the number of respondents who 
admitted to using alcohol more than they intended, increased 7 
percent among Army respondents after deployment to Iraq or 
Afghanistan.
    Alcohol and drug misuse are associated with a host of 
medical, social, mental health, and employment problems. 
Fortunately, those problems are treatable, and with treatment, 
the lives of our patients and their loved ones can be enriched.
    Since the implementation of the Mental Health Strategic 
Plan in VA, which began to be rolled out in 2005, the VHA has 
dedicated more than $458 million to improve the access and 
quality of care for veterans who present with substance use 
disorder treatment needs.
    We have funded 510 new substance use counselors; that's 
what my written testimony says, I checked this morning and it 
is actually about 520, and we plan to continue expanding 
substance use disorder services throughout fiscal year and next 
fiscal year.
    For example, this year, our mental health enhancement 
budget includes over $37.5 million for expanded substance use 
disorder services.
    Whenever a veteran is seen by a VA provider for the first 
time and then at annual retesting afterward, he or she is 
screened for PTSD, military sexual trauma, depression, and 
problem drinking. We recognize screening is only valuable if we 
act upon positive screens and follow-up in a timely manner, and 
we are committed to doing that.
    For those needing additional services when screening and 
evaluation has occurred our outpatient and inpatient substance 
use disorder programs are available; there are more than 220 
programs in place, with more in development.
    We maintain extended care facilities, including 19 
inpatient programs designed specifically to treat substance use 
disorder for 14 to 28 days. There are 44 residential 
rehabilitation treatment facilities that focus on substance 
use, 15 compensated work therapy programs with substance use 
particular emphasis, and 19 domiciliaries that focus on 
substance use disorder.
    Mental healthcare, including attention to substance use 
disorder, is being integrated into primary care clinics, and we 
also are integrating mental health services into our community-
based outpatient clinics, nursing homes, and our home-based 
primary care teams.
    Placing mental health providers in the context of primary 
care for the veteran is essential; it recognizes the 
interrelationships of mental and physical health, as well as 
providing mental healthcare at the most convenient and 
desirable location for the veteran.
    In addition to the care offered in medical facilities and 
community-based outpatient clinics, VA's Vet Centers provide 
outreach and readjustment counseling services to returning war 
veterans of all eras.
    It is well-established that rehabilitation for war-related 
PTSD, substance use disorder, and other military-related 
readjustment problems, along with the treatment of the physical 
wounds of war, is central to VA's continuum of healthcare 
programs specific to the needs of war veterans.
    The Vet Centers provide an alternative to traditional 
mental healthcare that helps many combat veterans overcome 
stigma and the fear related to accessing professional 
assistance for military-related problems.
    Substance use disorder is a real problem, and its 
manifestation along with other mental health conditions can 
lead to physical health concerns, difficulty readjusting to 
civilian life, and a host of other problems.
    One of VA's highest priorities is to reduce the impact of 
substance abuse and provide veterans with the care they need.
    Thank you for your time and for the opportunity to discuss 
this important issue with you. I would like to turn to 
addressing any questions that you have.
    [The prepared statement of Dr. Zeiss appears on p. 59.]
    Mr. Michaud. Thank you very much doctor. You had mentioned 
that you established 520 new substance use counselors. It is 
also my understanding that you downsized a number of years ago, 
so is this just getting you back to where you should be? But I 
guess the more important question is, I don't necessarily look 
at the increases or decreases, what I look at when I look at 
programs is, are you taking care of the problem?
    So how many of those 520 are actually onboard and are they 
taking care of the problem that we currently see out there 
today and do you have enough?
    Dr. Zeiss. Wonderful question and a very complex question.
    First of all let me say, it is absolutely true, there was a 
period in the history of VA's healthcare when there was a 
decline in availability of mental health and substance abuse 
treatment services. And the development of the Mental Health 
Strategic Plan in 2004 and its implementation beginning in 
2005, have just been essential and enormously important. And it 
has been paired with provision of strong resources, financial 
and support resources within VA, as well as the financial 
support we receive from Congress.
    So there has been a huge turnaround in the last couple of 
years, and we know that the mental health staff overall now is 
well above the levels at the historical high earlier which was 
around 1996 and 1997.
    We are above the earlier staffing for some components of 
substance use care, but because we also shifted from a 
primarily inpatient model of care to residential rehabilitation 
and intensive outpatient, the overall number of staff in 
substance use disorders would not be higher because there is 
not that round the clock nursing staff that would have been 
counted earlier. But in terms of our staffing to be able to 
cover the problem, I think that we are definitely well along 
the way, and we intend to continue to expand staff and to 
expand those services.
    You probably know that overall in VA in addition to the 
substance use positions that I have described, we have, in the 
last 2 years hired over 3,800 new mental health professionals 
and support staff. Almost entirely professional staff, but some 
support staff.
    So its really a very different VA than it was in 2004. And 
maybe with that I can let you say a bit, Dr. Allen, about some 
of the changes.
    Mr. Michaud. Are all 520 hired?
    Dr. Zeiss. Over 90 percent are.
    Mr. Michaud. Over 90 percent.
    Dr. Zeiss. There's about 50 still in the works.
    Mr. Michaud. Okay.
    Dr. Zeiss. They are in the pipeline. They are coming along 
to be hired.
    Mr. Michaud. If Dr. Allen could address this also, we heard 
Mr. Bowers earlier mention about the Vet Centers, are they all 
fully staffed and running as well?
    Dr. Zeiss. We will turn to Mr. Flora then first.
    Mr. Flora. Well I am happy to tell you that, and I'm sure 
that you know that we're adding 23 new Vet Centers and adding 
clinical staff at 61 existing Vet Centers.
    And I am happy to report that 20 of those Vet Centers are 
staffed and seeing clients. Some of them are still in temporary 
space. They are waiting for the contracting for the lease, for 
the property to get resolved, and only three of them are left 
to bring up. They will all be up before the end of this year. 
And staff are rapidly being hired in those remaining three and 
they're working diligently on the leasing process.
    So we should be up and running with all 23 new Vet Centers 
before the end of this fiscal year.
    Mr. Michaud. And what about the existing Vet Centers, are 
they fully staffed?
    Mr. Flora. Eighty percent done.
    Mr. Michaud. And what's that twenty percent as far as 
numbers? And when will they be fully staffed?
    Mr. Flora. Very soon. At the end of this fiscal year.
    Mr. Michaud. Okay. Thank you. And Dr. Allen?
    Dr. Allen. I am still relatively new at VA. I suppose 
coming into this system there are several things that I am 
impressed with that we are doing a very good job on. One of 
them is the screening for alcohol problems.
    I know of no system in the United States that does the 
amount of screening for alcohol problems as the Veterans 
Administration does. Right now we are screening close to 100 
percent of individuals who access our system. At the time they 
access the system and annually thereafter.
    As has been brought up by previous panels the importance of 
doing brief intervention is to try to address alcohol problems 
in their earlier stages when they are, in fact, more malleable. 
This is coming along extremely well. Right now we have 98, what 
we refer to as ``primary care mental health service'' 
providers. In many cases, more than one provider is at a 
facility. But in this arrangement the mental health provider is 
coordinated directly with the primary healthcare staff. And so 
the brief intervention is done on-site and if the veteran does 
not respond to the brief intervention we certainly hope they 
will and the data are quite favorable then they are referred to 
specialty care. So I think that's quite good.
    Another area that has been developing quite well has been 
the use of buprenorphine. There was a comment made about that 
there was not adequate use of methadone. It is true, our 
numbers for methadone maintenance have remained pretty constant 
since about 2004. But the number of patients who are now on 
Buprenorphine has increased by a factor of 4. Buprenorphine can 
be given in a primary healthcare center. And part of the 
advantage of that, is to diminish some of the stigma of going 
to a specific methadone maintenance program.
    Another area that I think we are doing extremely well in is 
in the ``clinical practice guideline'' arena. The Department of 
Defense and the Veterans Administration together do clinical 
practice guidelines, based upon to the extent possible, the 
best research evidence. And when it is not, when we simply do 
not have the evidence, then it is based on informed clinical 
opinion. The new substance use disorder guidelines for DoD and 
VA are nearly complete. We expect them to be complete within 
the next 6 years. I'm sorry, the next 6 months.
    I have reviewed the draft and it is quite good and I think 
addresses a number of the concerns about quality. This topic of 
addiction is actually quite heavily researched. There are now 
probably close to 300 controlled clinical trials on what works 
in treatment, and it is because of that the VA is committed to 
propagating and developing training programs on evidence-based 
treatments for addressing substance use disorders.
    The other topic I would like to address, which has been 
raised by a number of the other witnesses, has to do with the 
nexus between PTSD and substance use disorder. These problems 
do often co-occur. And in fact some of research suggests that 
when you have an individual, a returning servicemember, who 
suffers both problems the treatment prognosis is worse for both 
problems than if you had substance use with another psychiatric 
problem or if you had ``pure'' substance use disorder.
    So we are trying to address these together. Right now we 
have in all of our medical treatment facilities a team of 
providers who are dedicated to PTSD. On 12 of those teams we 
have a substance use disorder specialist and we have plans of 
adding this kind of resource to all of the other teams. The 
important thing, I think, with the treatment of substance use 
and collateral psychiatric problems is the care needs to be 
coordinated. Either done in an integrated fashion or else at 
least coordinated in a sequenced way where you would have a 
case manager who would assure that both kinds of care are being 
given. But, in short, my initial impressions of this system 
have been quite favorable.
    Mr. Michaud. Well I have several more questions, but I will 
recognize Ms. Berkley.
    Ms. Berkley. Thank you, Mr. Chairman.
    I work very closely with my VA back home and I know what a 
challenging job you have, and I thank you for all of your 
efforts on behalf of our vets. And I know sometimes our 
veterans have unrealistic expectations of what can be provided, 
and we've tried to have very frank discussions with veterans 
that call my office making requests that we can't possible 
fulfill.
    There was a time a few years ago and the head of the VA sat 
here presenting his budget, which was several billion dollars 
less than The Independent Budget that the veterans 
organizations provided to Congress, and we kept questioning the 
VA secretary of how could he possibly do what needs to be done 
with the budget he is presenting. And he assured us that the 
budget was fine. We practically threw an extra billion dollars 
at him, which he respectfully refused and I think it was going 
to be through attrition or technology that we would save all 
these billion of dollars and have plenty of money to take care 
of our vets. Six months later he was sitting where he was 6 
months before asking us for that billion that we had asked him 
if he needed 6 months earlier that he assured us he did not 
need. Well, he needed it. And I've sat in hearings with the 
head of the U.S. Department of Agriculture that assured us that 
there were no additional funds necessary for inspectors, and 
then the following week we saw those horrific pictures on 
television of the down cattle and we are told that they did not 
have enough inspectors, which one shakes their head and says 
what. They have a perfect opportunity to be sitting in front of 
Congress and tell us what the needs are and they chose not to. 
With billions of dollars of toys that are coming into this 
country and toothpaste and other products from China, when the 
head of the consumer products safety commission tells us that 
she does not need additional inspectors, you have got to think 
that this woman ought to be fired, or is smoking one of the 
substances that we are talking about today.
    So my question to you is, if we were living in a perfect 
world, and there were unlimited resources and you can come 
before a Congressional Subcommittee and tell us what you need 
from us so that you can do the job that we have tasked you 
with, what would you tell us you needed?
    Dr. Zeiss. Well I would respond first by pointing out that 
the percentage increase in VA population that we are serving, 
has been about, I can submit the specific numbers later, has 
been about 3 percent and the budget increase over the last 3 
years has been about 15 percent.
    So the budget increases have been running well ahead of the 
increased work load, and personally as I said earlier, I think 
that we have appropriately devoted a large amount of that to 
correcting decline in mental health and substance abuse 
services that had previously developed. And I will actually 
point out Dr. Dick McCormick, who was on an earlier panel, when 
he was with VA was very instrumental in helping to focus and 
start things on a path that I'm thrilled to be a part of 
implementing.
    At this point I think that what we are actually planning to 
come forward with is that, the resources that we have been 
getting have been primarily medical care dollars and we have 
been using them intensively for very effective hiring and 
expansion of our mental health workforce, but we have lagged in 
terms of getting from Congress medical facility dollars.
    All those 3,800 new staff need offices. They need places to 
see veterans. They need renovations, sometimes, in space. So 
there are a number of needs in terms of medical facility 
dollars, and we are actually planning to submit a white paper 
in relation to some upcoming thoughts about budget.
    So I would say for me, that is the really the main thing 
that would be tremendously helpful to us as we have grown so 
enormously.
    Ms. Berkley. Let me ask you another question, and I do not 
know if anybody can answer this, but I am sure you were in the 
room when I shared the story of Justin Bailey.
    Dr. Zeiss. Yes.
    Ms. Berkley. How does something like that happen, and what 
can we do in the future to prevent it? I mean, I have 
introduced this legislation. Is this the end-all-be-all cure 
for something like this. I had gotten to know his family very 
well. His father is a schoolteacher in our school district. 
This is a solid family and I could feel it. I have two sons and 
I could just imagine the pain that they feel on daily basis. 
What went wrong and what can we do to prevent it from happening 
again, so other families do not experience this horrific loss?
    Dr. Zeiss. Thank you for raising it. I wanted to raise it 
proactively if you had not, because it was clearly a terrible 
event. I personally went out to the LA Veterans Affairs 
Hospital along with a team, particularly the leadership of the 
residential rehabilitation staff. We did a very careful 
analysis of the what had gone wrong and you are quite correct. 
There were some issues around medication--not mental health 
medication, it was pain medication, but it could and should 
have been handled differently.
    We left a number of recommendations that were essentially 
requirements with that VA, and we also came back and generated 
resources to get out to them so they could implement those 
recommendations. And the handbook for the residential 
rehabilitation treatment programs was rewritten, particularly 
with even stronger emphasis on a staged model of self-
medication, which had already been there, but needed real 
strengthening. That handbook is going to final concurrence 
within VA, but in the meantime, even before final concurrence, 
the staff that guide residential rehabilitation have been 
implementing this. There has just been, 2 weeks ago, a 
conference for the leadership of the residential rehabilitation 
treatment programs and will continue to be similar things.
    And I personally went out about 3 weeks ago to Los Angeles 
again, to follow up and make sure that things were being 
changed that needed to be changed.
    I think the other huge issue there was that, that was a 
domiciliary-type of residential rehabilitation program, and as 
part of the mental health strategic plan, the domiciliary 
switched from, Geriatrics and Extended Care to Mental Health. 
Even before a Department of Veterans Affairs had existed, there 
had been a Domiciliary Program. It had been under geriatrics 
and extended care within Veterans Health Administration and one 
of the recommendations of the strategic plan was to transfer 
that to the Office of Mental Health Services. That did happen 
in 2005.
    There had been some sites that have had more difficulty 
shifting their model of care to one of recognizing that these 
are really mental health programs. By the way, one of the 
reasons for that shift is that we had data showing that over 90 
percent of the residents of the domiciliaries had a mental 
health or substance use disorder diagnosis. So clearly there 
needed to be a different model of care.
    So I assure you we have been reorganizing the reporting 
mechanisms, the funding mechanisms, the guidance and oversight 
at those residential rehabilitation facilities because we agree 
with you that it is just not acceptable for something to happen 
like what happened to Justin Bailey.
    Ms. Berkley. Mr. Chairman, before Mr. Hare left he said I 
could have his five minutes. Could I take two of his five?
    Mr. Michaud. No problem because I have more questions as 
well. So feel free. You can take all of his five.
    Ms. Berkley. I am sure he said that as he walked out.
    Mr. Michaud. You can take all of his five you would like.
    Ms. Berkley. I do not think I need to, it depends on their 
answers.
    Let me share with you another gut-wrenching story. When 
anybody dies from the State of Nevada whether they live in my 
Congressional district or not, if they lose their life in 
service to our country I call the families, and offer any help 
that I could provide and just talk to them, and just sometimes 
they just--actually most of the people need hotel rooms in Las 
Vegas because they have got family coming for the memorial 
service, and we try to help and the hotels have been very 
accommodating.
    One phone call I made was to a grandmother in Pahrump, 
Nevada, which is a bedroom community about fifty minutes from 
Las Vegas. She had raised her grandson, so she was the 
appropriate person to call when he killed himself in Iraq.
    This was the story that she shared with me, although I knew 
it before I called her.
    Her grandson had served a tour of duty in Iraq, came home 
and 3 months later he was advised that he would be shipped 
back. He was having serious emotional problems, did not want to 
go back. Begged his grandmother to do something to keep him 
from going back. He was interviewed by a psychologist or 
psychiatrist with the DoD who diagnosed him as being depressed 
and gave him Prozac and sent him back to Iraq.
    He was on suicide watch in Iraq. They knew that he had an 
emotional problem and he was suicidal. After a certain amount 
of time they took him off of suicide watch and the following 
day he killed himself.
    Now, had he not killed himself, and had completed his tour 
and come home, he would have been an emotional basket case that 
needed intervention and help.
    I know that our military is very stretched right now. Do 
you think that we are accepting into our volunteer military and 
keeping people that should not be there because of emotional 
problems, just so we have bodies on the ground in Iraq and 
Afghanistan? And do you see an uptick in those type of cases of 
people that should never be serving in the first place, so if 
they can get through their tour and they come home as veterans, 
they become, and I don't mean to--when I say burden I don't 
mean this is a negative sense, but I would imagine we have a 
number of people currently with PTSD and other emotional issues 
and substance abuse issues, that never should have been in the 
military in the first place. Are you seeing any of that? I'm 
not asking to step out of your role and speak policy, could 
have, would have, should have, but I am kind of wondering, are 
you seeing an uptick in this? Are there people that are now 
coming into the VA as veterans that never should have been in 
the active military in the first place?
    Dr. Zeiss. Well I am going to say I am not going to speak 
to whether or not they should have been in the military in the 
first place. Those are decisions for a different department and 
our job is to take care of people when they return.
    I am happy to talk about what we are seeing among veterans 
who are returning, and what we have put in place and will 
continue to enhance.
    We certainly see a high number of returning folks who do 
have mental health problems. At this point there are 300,000 
returning Iraq/Afghanistan veterans who have sought care from 
VA, and of those--no that is overall--and of those 40 percent 
have been potentially diagnosed with a mental health concern. 
Some of those are rule out diagnosis and will not be final 
diagnosis, but at least they need careful evaluation because of 
possible mental health problems.
    So that is about 120,000 folks, and of those about half 
have a possible PTSD diagnoses. The second largest is 
depression. The third largest is if you put all the substance 
use disorders together they would make up the third largest 
category of diagnosis.
    So there is no question that VA is seeing a high rate of 
mental health concerns in those veterans who seek care from VA. 
We can only speak to those who come and to service us. But we 
follow those data very carefully. We get quarterly reports on 
the increased number of veterans that we are seeing Iraq and 
Afghanistan and what are the major diagnosis that they are 
coming back with. Not just mental health but overall because it 
is important to integrate the mental healthcare with the other 
kinds of physical healthcare that these veterans have.
    So I assure you we are very carefully attending to what is 
the information about the breadth of problems that people 
return with, and what does that mean we need to be ready to do.
    Mr. Michaud. Earlier in my opening statement, I talked 
about reports out there that suggest that up to 70 percent of 
homeless veterans have a substance use disorder. What 
specifically is the VA doing to address this disorder among our 
homeless veterans?
    Dr. Zeiss. Well we are doing a number of things. Again I 
can speak first, and then I will let my colleagues also address 
this.
    We do not have with us Paul Smits, who is the head of our 
homeless section in the Officer of Mental Health Services. A 
splendid person who has, I know, testified many times.
    We have a large expanding homeless outreach and homeless 
service program that includes many dimensions of care. It 
includes the residential rehabilitation programs, 
domiciliaries, grant and per diem programs. We have a new U.S. 
Department of Housing and Urban Development--Veterans Affairs 
Supportive Housing Program that has been funded by Congress 
that we are in the process of implementing. And they do 
extensive outreach, along with the outreach that we can let Mr. 
Flora speak about that the Vets Centers do so splendidly.
    We have many programs that are specifically designed to 
work very particularly with substance use disorder in homeless 
populations.
    I would say--I am sorry Ms. Berkley has left--one of the 
things that is a strength of the LA VA where Justin Bailey's 
unfortunate death occurred, is that they take in homeless 
substance-using veterans who are extremely high risk and where 
that community has documented several times in newspapers 
stories other parts of the private healthcare system dumping 
people back on skid row. The VA has never done that, will never 
do that, and keeps people who are at very high risk in our 
treatment programs.
    Mr. Michaud. You mentioned the grant and per diem problem. 
I know from talking to the folks that deal with that program, 
there is also a problem with grants and per diem depending on 
what region of the country that you live in, as far as their 
reimbursement rate. Are you working with these organizations as 
well to make sure that they are adequately reimbursed?
    Dr. Zeiss. I know that Paul Smits is working very much on 
that and I'm not the expert on that, but, yes, it is certainly 
something that is followed carefully.
    The other important thing about the grant and per diem 
program, I just want to stress that may not come up in those 
discussions about the reimbursement, is that we fund from our 
mental health enhancement budget the liaisons that go out to 
those grant and per diem programs, which are not VA programs 
per se, to make sure that those homeless veterans get linked 
into our VA substance use disorder and mental health programs 
and who function as case managers.
    So it is above and beyond just providing the place to live 
that is reimbursed through the grant and per diem funding that 
you were mentioning. It is a much more complex program than 
that.
    Mr. Michaud. You heard Mr. Bowers talk about this this 
morning, and you mentioned it several times that you are 
addressing the needs of those who actually come forward for 
assistance, however there are a lot out there that do not, and 
Mr. Bowers said, I think, it took him like 3 years before he 
actually had the information that he really thought was helpful 
for a veteran to be able to get the services that they need. 
And he actually recommended that it be mandatory that they go 
through that type of coming back home with different programs.
    Do you agree with that, that they should be mandatory? I 
guess it gets back to my earlier statement that I am very 
pleased that Dr. Kussman actually issued a directive that VA 
facilities to ensure that no veteran is denied PTSD treatment 
because of substance use disorder. So it leads me to ask, why 
did Dr. Kussman give that directive? Is it because they were 
being denied? And so if you could address that, and whether or 
not we should mandate that they receive the training that Mr. 
Bowers had mentioned a little bit earlier.
    Dr. Zeiss. Yeah. Well two wonderful questions. The first 
one, which is about the PDHRA screens, I am happy to ask Mr. 
Flora to respond to, because the Vet Centers are always there.
    Mr. Flora. The Vet Centers and a representative from the VA 
Medical Center has been at every PDHRA event that has occurred 
over the last couple of years. This is facilitated with the 
Department of Defense. We have Colonel Terry Washam, who is a 
VA employee, who is the main point of contact in the seamless 
transition group that sets these up. But we have been at every 
one of them. And also since 2003, 2004, the Vet Centers have 
undertaken a very aggressive outreach program. And I am sure 
you know we hired the 100th Global War on Terrorism Outreach 
Specialists and they have been extremely active at 
demobilization sites providing the kind of information that was 
talked about. And I was very gratified to hear Mr. Bowers say 
that he had an excellent relationship with the Vet Centers. I 
think he said locally, but he got exactly the kind of 
information that he needed.
    And if you would not mind, sir, I'd like to go back to the 
first question that you asked me, and say, we would be happy to 
provide you a detailed report about where we are with our new 
Vet Center resources.
    I'm absolutely sure about the new Vet Centers numbers, but 
we can tell you, where we are augmenting staff and give you a 
very detailed picture.
    [The following was subsequently received:]

          In February 2007, VA announced plans to increase the number 
        of Vet Centers from 209 to 232 and to augment the staff at 61 
        existing Vet Centers by one staff position each. Based upon the 
        criteria of having hired staff and providing services to 
        veteran clients, 20 of the projected 23 new Vet Centers are 
        currently open. All 23 Vet Centers will be open by the end of 
        the fiscal year. Fifteen Vet Centers are fully open with a 
        signed lease and hired staff, and are providing services to 
        veterans in Binghamton, NY; Middletown, NY; Watertown, NY; 
        Hyannis, CT; DuBois, PA; Gainesville, FL; Melbourne, FL; Macon, 
        GA; Manhattan, KS; Escanaba, MI; Saginaw, MI; Grand Junction, 
        CO; Baton Rouge, LA; Killeen, TX; and Las Cruces, NM.
          Five Vet Centers have hired staff and are providing client 
        services, but are operating out of temporary space while they 
        finalize their lease contracts. They are located in Toledo, OH; 
        Ft. Myers, FL; Montgomery, AL; Everett, WA; and Modesto, CA.
          Three Vet Centers are actively pursuing and/or completing 
        staff recruitment and lease contracting. In Berlin, New 
        Hampshire, the lease has been signed and the Team Leader, 
        Office Manager and one Counselor have been hired. VA has hired 
        a Team Leader in Nassau County, NY, and Fayetteville, AR.
          The 61 existing Vet Centers selected for augmentation are 
        Mobile, AL; Tucson, AZ; Anaheim, Concord, Corona, Fresno, Los 
        Angeles, Sacramento, San Bernardino, San Diego, San Jose, Santa 
        Cruz County, Ventura and Vista, CA; Boulder, CO; New Haven and 
        Norwich, CT; Jacksonville, Palm Beach, Pensacola, Sarasota, 
        Tallahassee and Tampa, FL; Honolulu and Maui, HI; Cedar Rapids 
        and Sioux City, IA; Boise, ID; New Orleans and Shreveport, LA; 
        Brockton, New Bedford, Springfield and Worcester, MA; Caribou, 
        ME; Charlotte, Greensboro and Greenville, NC; Lincoln, NE; 
        Trenton, NJ; Albuquerque and Farmington, NM; Rochester, NY; 
        Cleveland and Columbus, OH; Oklahoma City, OK; Portland, OR; 
        Harrisburg, PA; Austin, El Paso and San Antonio, TX; Provo, UT; 
        Alexandria and Norfolk, VA; Spokane and Tacoma, WA; Madison and 
        Milwaukee, WI; and Beckley, Princeton, and Wheeling, WV. 
        Currently 49 (or 80%) of the augmented positions are filled. 
        The remaining 12 positions are under recruitment and will be 
        hired by the end of the fiscal year.
          The following chart provides additional information regarding 
        where VA is in the context of rural healthcare.


                                                    End of Fiscal Year 2006 Enrollees and Patients *
                                                           VA Sites by State and percent rural
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                            Total EOY06      Urban       Rural     Highly rural     Total EOY06      Urban       Rural     Highly rural
                                             Enrollee      Enrollee    Enrollee      Enrollee         Patient       Patient     Patient       Patient
--------------------------------------------------------------------------------------------------------------------------------------------------------
National                                     7,848,282    4,879,424   2,850,173      118,685         4,877,733    2,919,645   1,878,624       79,464
--------------------------------------------------------------------------------------------------------------------------------------------------------
% Total                                                       62.2%       36.3%         1.5%                          59.9%       38.5%         1.6%
--------------------------------------------------------------------------------------------------------------------------------------------------------
Alabama                                        148,220       67,954      80,266            0            90,727       41,007      49,720            0
--------------------------------------------------------------------------------------------------------------------------------------------------------
Alaska                                          24,695       12,934       3,703        8,058            12,700        6,940       1,745        4,015
--------------------------------------------------------------------------------------------------------------------------------------------------------
Arizona                                        181,233      116,668      59,704        4,861           110,960       69,146      38,991        2,823
--------------------------------------------------------------------------------------------------------------------------------------------------------
Arkansas                                       114,753       37,740      77,013            0            80,785       25,990      54,795            0
--------------------------------------------------------------------------------------------------------------------------------------------------------
California                                     638,769      530,070     106,432        2,267           353,793      287,553      64,841        1,399
--------------------------------------------------------------------------------------------------------------------------------------------------------
Colorado                                       107,864       74,541      26,974        6,349            63,213       42,444      16,650        4,119
--------------------------------------------------------------------------------------------------------------------------------------------------------
Connecticut                                     80,575       69,354      11,221            0            51,093       44,258       6,835            0
--------------------------------------------------------------------------------------------------------------------------------------------------------
Delaware                                        22,531       13,820       8,711            0            12,961        7,974       4,987            0
--------------------------------------------------------------------------------------------------------------------------------------------------------
DC                                              16,113       16,113           0            0             9,417        9,417           0            0
--------------------------------------------------------------------------------------------------------------------------------------------------------
Florida                                        637,881      510,316     127,565            0           426,443      337,559      88,884            0
--------------------------------------------------------------------------------------------------------------------------------------------------------
Georgia                                        223,736      131,388      92,348            0           128,983       71,908      57,075            0
--------------------------------------------------------------------------------------------------------------------------------------------------------
Hawaii                                          33,478       23,424      10,054            0            18,361       12,302       6,059            0
--------------------------------------------------------------------------------------------------------------------------------------------------------
Idaho                                           46,439       22,410      18,332        5,697            31,041       14,965      12,277        3,799
--------------------------------------------------------------------------------------------------------------------------------------------------------
Illinois                                       285,615      193,965      91,650            0           170,266      111,603      58,663            0
--------------------------------------------------------------------------------------------------------------------------------------------------------
Indiana                                        161,719       89,256      72,463            0           108,147       58,688      49,459            0
--------------------------------------------------------------------------------------------------------------------------------------------------------
Iowa                                            94,290       30,942      63,348            0            65,769       21,287      44,482            0
--------------------------------------------------------------------------------------------------------------------------------------------------------
Kansas                                          82,282       32,880      43,947        5,455            57,882       23,189      30,540        4,153
--------------------------------------------------------------------------------------------------------------------------------------------------------
Kentucky                                       131,155       50,975      80,180            0            89,009       33,783      55,226            0
--------------------------------------------------------------------------------------------------------------------------------------------------------
Louisiana                                      126,172       66,848      59,324            0            79,488       39,485      40,003            0
--------------------------------------------------------------------------------------------------------------------------------------------------------
Maine                                           50,610       10,428      39,100        1,082            36,817        7,263      28,763          791
--------------------------------------------------------------------------------------------------------------------------------------------------------
Maryland                                       126,809      100,329      26,480            0            71,304       55,886      15,418            0
--------------------------------------------------------------------------------------------------------------------------------------------------------
Massachusetts                                  132,529      120,286      12,243            0            77,558       70,342       7,216            0
--------------------------------------------------------------------------------------------------------------------------------------------------------
Michigan                                       184,417      108,574      75,223          620           115,772       65,499      49,820          453
--------------------------------------------------------------------------------------------------------------------------------------------------------
Minnesota                                      129,266       55,016      72,035        2,215            89,836       36,322      52,059        1,455
--------------------------------------------------------------------------------------------------------------------------------------------------------
Mississippi                                     95,968       26,773      69,163           32            66,915       17,585      49,307           23
--------------------------------------------------------------------------------------------------------------------------------------------------------
Missouri                                       178,250       82,667      95,583            0           121,713       53,962      67,751            0
--------------------------------------------------------------------------------------------------------------------------------------------------------
Montana                                         42,131        9,727      19,081       13,323            29,023        6,391      13,437        9,195
--------------------------------------------------------------------------------------------------------------------------------------------------------
Nebraska                                        60,765       23,746      31,163        5,856            40,838       14,695      21,951        4,192
--------------------------------------------------------------------------------------------------------------------------------------------------------
Nevada                                          86,337       66,523      12,064        7,750            52,324       39,789       7,735        4,800
--------------------------------------------------------------------------------------------------------------------------------------------------------
New Hampshire                                   37,107       15,377      21,730            0            24,774        9,963      14,811            0
--------------------------------------------------------------------------------------------------------------------------------------------------------
New Jersey                                     158,295      147,743      10,552            0            78,629       73,297       5,332            0
--------------------------------------------------------------------------------------------------------------------------------------------------------
New Mexico                                      67,513       31,260      27,916        8,337            45,149       20,917      18,240        5,992
--------------------------------------------------------------------------------------------------------------------------------------------------------
New York                                       460,464      334,594     125,682          188           232,308      162,853      69,361           94
--------------------------------------------------------------------------------------------------------------------------------------------------------
North Carolina                                 245,773      112,961     132,812            0           160,503       72,354      88,149            0
--------------------------------------------------------------------------------------------------------------------------------------------------------
North Dakota                                    25,201        8,811      10,518        5,872            16,549        5,723       6,811        4,015
--------------------------------------------------------------------------------------------------------------------------------------------------------
Ohio                                           304,456      194,686     109,770            0           186,240      117,788      68,452            0
--------------------------------------------------------------------------------------------------------------------------------------------------------
Oklahoma                                       120,601       47,267      72,347          987            78,603       29,498      48,480          625
--------------------------------------------------------------------------------------------------------------------------------------------------------
Oregon                                         115,387       52,163      58,358        4,866            76,514       33,288      39,896        3,330
--------------------------------------------------------------------------------------------------------------------------------------------------------
Pennsylvania                                   361,114      230,399     130,715            0           228,985      144,361      84,624            0
--------------------------------------------------------------------------------------------------------------------------------------------------------
Rhode Island                                    27,957       25,378       2,579            0            19,650       17,902       1,748            0
--------------------------------------------------------------------------------------------------------------------------------------------------------
South Carolina                                 144,972       75,369      69,603            0            93,181       47,064      46,117            0
--------------------------------------------------------------------------------------------------------------------------------------------------------
South Dakota                                    38,675       10,046      17,440       11,189            28,529        7,309      12,724        8,496
--------------------------------------------------------------------------------------------------------------------------------------------------------
Tennessee                                      169,858       88,391      81,467            0           111,087       56,943      54,144            0
--------------------------------------------------------------------------------------------------------------------------------------------------------
Texas                                          570,121      364,420     198,450        7,251           361,386      224,353     132,167        4,866
--------------------------------------------------------------------------------------------------------------------------------------------------------
Utah                                            45,924       34,605       6,809        4,510            28,570       21,679       4,171        2,720
--------------------------------------------------------------------------------------------------------------------------------------------------------
Vermont                                         20,779        2,282      18,497            0            14,185        1,535      12,650            0
--------------------------------------------------------------------------------------------------------------------------------------------------------
Virginia                                       193,291      119,645      73,572           74           109,106       62,586      46,464           56
--------------------------------------------------------------------------------------------------------------------------------------------------------
Washington                                     158,147      111,232      45,375        1,540            86,285       60,340      24,960          985
--------------------------------------------------------------------------------------------------------------------------------------------------------
West Virginia                                   84,795       24,758      60,037            0            56,834       16,131      40,703            0
--------------------------------------------------------------------------------------------------------------------------------------------------------
Wisconsin                                      145,105       66,367      78,738            0           100,087       44,689      55,398            0
--------------------------------------------------------------------------------------------------------------------------------------------------------
Wyoming                                         23,892        7,173       6,413       10,306            16,462        4,890       4,504        7,068
--------------------------------------------------------------------------------------------------------------------------------------------------------
Puerto Rico                                     84,253       78,830       5,423            0            60,979       56,950       4,029            0
--------------------------------------------------------------------------------------------------------------------------------------------------------
* Excludes non-enrolled non-Veterans and Priority 8e, 8g.



    Mr. Michaud. Yeah, I appreciate that very much.
    Dr. Zeiss. In terms of the directive, we feel passionately 
about it and so I'm glad that you recognize it. And it does not 
just say that treatment for PTSD cannot be denied--it is any 
mental health problem. And the reason that it was released is 
because we knew not only of anecdotal reports of some people 
being refused treatments, but also that there were some 
programs who had policies that if someone was using substances 
they would not be eligible. That is reasonable and I'll ask Dr. 
Allen to speak more to that. But it is not reasonable to say, 
therefore no care will be provided. That is absolutely 
unreasonable. The appropriate level of care needs to be 
provided.
    Dr. Allen. It is almost a patient ``bill of rights'', if 
you will, which says that substance use problems are always to 
be addressed, but they are to be addressed appropriately. For 
example, if you have a veteran that is in one of the 
residential rehabilitation treatment programs and the 
individual is actively using substances, that person may be 
transferred out of that facility because of the risk that he or 
she would present to other patients, but they are still 
treated. And in fact, if the veteran is approached on the need 
for care, and refuses, they are still called to see if things 
have changed.
    One other thing I would like to mention, the PDHRA event 
that was alluded to earlier, occurs 90 to 180 days post 
deployment. These events are set up by the Department of 
Defense, and, in fact, the PDHRA is mandatory for redeploying 
servicemembers. It is more difficult sometimes if it is a 
National Guard unit that is in a more remote site, or a Reserve 
unit, than if it is an active-duty unit, but they are 
mandatory. I went through it myself, in fact. But the VA is 
always there and the Vet Centers are always there with a 
representative.
    So we tried to tighten up that linkage. I do agree it does 
not always happen. It should not have been 3 years. It should 
have been 90 days to 180 days after return. That is a problem 
in that unit.
    Mr. Michaud. You mentioned Guard and Reserve is more 
difficult, but yet when you look at the war in Iraq and 
Afghanistan with the number of redeployments and the length of 
redeployments and the fact that there are so many Guard and 
Reserves over there, how do you close that gap so that the 
Guard and Reserves are not hit and miss?
    Dr. Allen. There is supposed to be a dwell time, and I am 
sorry I do not know the DoD policy on that, but typically the 
redeploying servicemember is home at least as long as he or she 
was deployed previously. And I think, and again it is simply 
what the newspapers were indicating, yet there may be a 
requirement that it is twice as long as they were in the 
country. But there is a dwell time that the individual must be 
here.
    Mr. Michaud. Earlier, actually, I believe Dr. McCormick 
mentioned that there were gaps in services. But also if you 
look at what is happening nationwide, one facility might be 
doing a very good job, another facility is not doing a very 
good job, and hopefully we will come up with a report card on 
each facility. Do you see that variation between facilities as 
far as the actual services that they might be receiving or not 
receiving?
    Dr. Allen. At this point there is variability, but I can 
say that every VA Medical Center has a substance abuse 
treatment program. They differ in terms of the availability of 
residential rehabilitation programs and intensive outpatient 
programs.
    We have a staffing model for the intensive outpatient 
programs that looks at the number of veterans in an area, the 
percent that are dual diagnoses and helps us decide if it is 
warranted to set up an entire program there. If it is not, the 
services can be contracted out, and they can be contracted out 
to community agencies, and that would likely be the case in 
more remote parts of the country where you simply don't have 
enough veterans for this to be under our roof. But there is a 
strong movement toward standardization of services.
    Apparently, at one time, the Veterans Administration became 
highly decentralized and so you have a tremendous amount of 
discretion at the regional levels. There is an effort now to 
look at better standardization of services and opportunities so 
that there will be certain treatment opportunities that must be 
made available to all veterans regardless of where they live, 
although the mechanism for providing them may well be a 
contract. It might be telemedicine or if there are enough 
people there it would be under our own roof but we are 
concerned about the problem.
    Mr. Michaud. When you contract out, how do you know, it 
there a witness test that you make sure that wherever you are 
contracting out? Because one of the things that we heard a few 
meetings ago is to make sure that we have qualified providers 
out there, and how do you determine that?
    Dr. Allen. Toni, Do you want to address that?
    Dr. Zeiss. Those decisions are made at the local level, so 
we can gather more information for you if you would like, but 
our role at central office is to indicate what are the kinds of 
services that need to be provided and to work with the local 
folks to determine what is the best way to provide it.
    The range of possibilities, I think, just to pull them all 
together, you've heard about them in a more scattered way, is 
first certainly for veterans to come to a VA Medical Facility 
where there will be the most complex and breadth of services.
    Second, to go to a community based outpatient clinic, where 
there are now mental health staff at most clinics, and get 
services there. There is telemental health, and you have been 
asking about some other more high-tech ways of delivering 
service, and we have been working on various fronts with that. 
But telemental health is a way to really link people to more 
specialized care at the medical facility who are out getting 
their care from community based outpatient clinics. And then 
ultimately, if someone is really too far away even from a 
community based outpatient clinic, there is the possibility to 
contract care. And the requirement is that the local facilities 
develop memorandums of understanding that clearly lay out what 
are the kinds of services and who are the providers. But we 
don't require that those be approved at the national level.
    Something else, but let me stop there and see what 
questions that raises.
    Mr. Michaud. Yes, back in, I believe, 2006, the VA did a 
PTSD Report. When is the next report due out? Do you have 
another report? The special Committee?
    Dr. Zeiss. If you mean the report of the special committee, 
it is annual, and I think that the current one, if it has not 
been released to Congress, it is in its final review prior to 
that release.
    Mr. Michaud. Okay.
    Dr. Zeiss. Is it still in review. Yeah. Okay. So it is 
forthcoming.
    Mr. Michaud. You heard my questions earlier about the 
Surgeon General and the Deputy Undersecretary when they were 
talking to the VFW and it was brought to my attention from a 
veterans service organization, that they have this new 
classification or it is at least the first time I ever heard of 
it, PTSD-NR. What is PTSD-NR?
    Dr. Zeiss. It was the first we had heard of it, too, and I 
suspect they were referring to the Diagnostic and Statistical 
Manual of Mental Disorders (DSM) IV, revised version. We use 
the most recent version of DSM IV for making PTSD diagnoses.
    I don't think that is NR, it is DSM IV R. But that may have 
snuck in. But I believe that is probably what they were talking 
about. I will go back and check.
    We use the diagnostic and statistical manual of the 
American Psychiatric Association as the absolute basis for the 
PTSD diagnosis.
    [After researching the term, the VA was unable to find out 
the origination or definition of the term, PTSD-NR.]
    Mr. Michaud. Right. And just the last few questions.
    As you know treatment of comorbid substance use disorder 
and other mental health conditions are very challenging, how 
does the VA ensure that they have the mental health 
professionals that are competent to treat these comorbid 
conditions and what research is VA doing on comorbid 
conditions?
    Dr. Zeiss. Do you want to start with this?
    Dr. Allen. Certainly.
    Well I think this is probably a question we should have for 
the record.
    The comorbidity thing is a difficult issue. I know that for 
our clinical psychologists, and we have increased the number of 
those people a lot, they have to be extremely well qualified. 
They must be licensed in the State. They must have taken their 
doctorate in a program that is approved by the American 
Psychological Association (APA), and their internship must be 
in a program approved by the American Psychological 
Association.
    So I think our standards are extremely high for our 
professional staff. Does that guarantee that they could treat 
comorbid conditions? I think so. If they are at that level that 
is what they have been licensed to do, and it is a challenging 
area. We obviously need to get smarter and better always.
    Dr. Zeiss. Let me just, for the record, fine-tune just a 
bit what Dr. Allen has said.
    For psychology and social work where professionals are not 
licensable until 1 to 2 years after they have completed their 
internship, VA can hire unlicensed psychologist and social work 
staff, but they must be professionally supervised during the 
period while they are completing licensing. And they must 
complete licensing within a short period of time if they are 
going to be able to maintain VA employment.
    So I think I would echo strongly what Dr. Allen is saying 
about the high credentials of our staff and especially the 
requirement that people have all their training from APA 
credited programs.
    The other thing I would say, is we know, again focusing 
specifically on psychology, that of recent hires in the last 
year to 2 years, of new psychology staff, over 75 percent of 
them have had training in VA before they were hired. And so 
they were getting at least part of their training, exactly with 
veterans who have a high rate of comorbid problems, and these 
trainees then enter our staff already with supervised 
experience in working with the nature of the problems that 
veterans present. And we happen to have that specific number 
for psychology. It is true for other professions, as well, 
because of the large training program that VA has.
    Mr. Michaud. What do you do in a situation since that 
standard is very high, and if a veteran that lives in a rural 
area might need that type of assistance, it is going to be very 
difficult because you might not have a provider that you would 
be able to contract out. So how do you close that gap in those 
particular situations? Do you have a handle on exactly how big 
that gap is?
    Dr. Zeiss. Well, we have an Office of Rural Health and we 
can take, for the record, specific questions. I have looked 
recently at their data and we know that the highly rural 
veteran population, which is defined by the number of folks per 
square mile or per acre--is 1.6 percent of the veteran 
population. But there are States where it is a much higher 
proportion and we are really looking to the Office of Rural 
Health to help guide us. And in fact I think they have recently 
submitted a plan for mental health and geriatric care to 
Congress based on their extensive analysis and collaboration 
with us.
    As I mentioned, the range of possibilities includes to 
expanding telemental health. I think the question you have 
asked earlier, is Internet-based therapy useful or not, and we 
would re-construe that question as what aspects of care can be 
provided effectively on an Internet basis. We have My 
HealtheVet, which is a web based set of rich information and 
screening information that veterans can access from their home 
computer. And it allows them to get some educational 
information about mental health and substance problems and to 
do some self screening.
    We are also working to develop the interactive capacities 
between My HealtheVet and medical facilities.
    So there could be secure messaging between providers and 
veterans. But we are not completely there yet, so that is being 
currently tested in the primary care context.
    So we think there are lots of avenues we need to pursue as 
we have been pursuing, to keep pushing the window and being 
able to do a better and better job with these rural veterans, 
who clearly face the most difficult obstacles in terms of 
getting care from VA, but also as you say, many of these 
communities do not have rich other resources for mental health 
and substance use care.
    Mr. Michaud. I want to thank you very much Dr. Zeiss, and 
Dr. Allen and Mr. Flora for your testimony today. I look 
forward to working with you and I know we will have some more 
follow up questions. This is a very important issue to Members 
of this Committee and it is one that we hopefully will be able 
to get a better handle on as we move forward to make sure that 
our veterans do receive the services that they need in a timely 
manner and that they have access to those services as well.
    So once again, thank you very much for your testimony 
today, I appreciate it.
    Dr. Zeiss. Thank you.
    Dr. Allen. Thank you.
    Mr. Flora. Thank you.
    Mr. Michaud. No further questions. The hearing is 
adjourned.
    [Whereupon, the Subcommittee was adjourned at 12:00 noon.]



                            A P P E N D I X

                              ----------                              

             Prepared Statement of Hon. Michael H. Michaud
                    Chairman, Subcommittee on Health
    I would like to welcome everyone to our Subcommittee hearing. We 
are here today to talk about treatment for substance abuse and comorbid 
conditions in the Department of Veterans Affairs.
    Substance use disorders are among the most common diagnoses made by 
the Veterans Health Administration. According to the 2007 National 
Survey on Drug Use and Health, 7.1% of veterans met the criteria in the 
past year for a substance use disorder and 1.5% of veterans had a co-
occurring substance use disorder. Of the approximately 300,000 veterans 
from Operations Enduring and Iraqi Freedom who have accessed VA 
healthcare, nearly 50,000 have been diagnosed with a substance use 
disorder.
    Additionally, more than 70% of homeless veterans suffer from 
alcohol and other drug abuse problems.
    Over the past several years, Congress has increased funding for 
substance use treatment programs within the Department of Veterans 
Affairs to $428 million in Fiscal Year 2008. I believe that continued 
adequate funding is imperative for the health and well-being of our 
veterans and their families.
    Substance use frequently co-occurs with other mental health 
conditions. VA needs to continue to dedicate itself to providing 
services that can address both substance use and other mental health 
conditions such as PTSD simultaneously.
    I also was pleased to learn that Dr. Kussman, VA's Undersecretary 
for Health recently released a directive on the management of substance 
use disorders. This directive states, among other things, that VA 
facilities must not deny care to any enrolled veteran because they are 
using substances and that all VA medical facilities must provide 
services to meet the needs of veterans with substance use disorders and 
PTSD. I think that this is a step in the right direction and I commend 
VA for it's proactive leadership on this issue.
    Last week, Mr. Miller and I introduced the Veterans Substance Use 
Disorder Prevention and Treatment Act of 2008. This legislation will 
require the VA to provide the full continuum of care for substance use 
disorders, and it will require this full spectrum of care to be 
available at every VA medical center. This legislation also directs the 
VA to conduct a pilot program for Internet-based substance use disorder 
treatment for veterans of Operations Enduring Freedom and Iraqi 
Freedom. This will enable our newest generation of veterans to overcome 
the stigma associated with seeking treatment and receive the necessary 
care in a comfortable and secure setting.
    The Committee realizes that substance use and comorbid conditions 
are complex issues. But we also recognize that it is an important one 
that deserves serious thought and consideration. I look forward to 
hearing from our panels today about ways that VA can effectively 
address these critical issues.

                                 
    Prepared Statement of Hon. Shelley Berkley, a Representative in 
                   Congress from the State of Nevada
    Mr. Chairman,
    Thank you for holding this hearing on this important issue of 
substance abuse and comorbid conditions.
    Nationally, one in five veterans returning from Iraq and 
Afghanistan suffers from PTSD. Twenty-three percent of members of the 
Armed Forces on active duty acknowledge a significant problem with 
alcohol use. It is vital that our veterans receive the help they need 
to deal with these conditions.
    The effects of substance abuse are wide ranging, including 
significantly increased risk of suicide, exacerbation of mental and 
physical health disorders, breakdown of family support, and increased 
risk of unemployment and homelessness. Veterans suffering from a mental 
health issue are at an increased risk for developing a substance abuse 
disorder.
    A constituent of mine, Lance Corporal Justin Bailey, returned from 
Iraq with PTSD. He developed a substance abuse disorder and checked 
himself into a VA facility in West Los Angeles. After being given 5 
medications on a self-medication policy, Justin overdosed and died.
    I have introduced the Mental Health Improvements Act, which aims to 
improve the treatment and services provided by the Department of 
Veterans Affairs to veterans with PTSD and substance use disorders by:

      Expanding substance use disorder treatment services at 
the VA Medical Centers.
      Establishing national centers of excellence on PTSD and 
substance use disorders.
      Creating a program for enhanced treatment of substance 
use disorders and PTSD in veterans.
      Requiring a report on residential mental healthcare 
facilities of the Veterans Health Administration (VHA).
      Creating a research program on comorbid PTSD and 
substance use disorders.
      Expanding assistance of mental health services for 
families of veterans.

    It is imperative that we provide adequate mental health services 
for those who have sacrificed for this great nation and those who 
continue to serve. This bill takes a step in the right direction in 
providing our veterans with the care they have earned. I urge my 
colleagues to cosponsor this important piece of legislation, and I look 
forward to further action in this Committee.

                                 
    Prepared Statement of Hon. John T. Salazar, a Representative in 
                  Congress from the State of Colorado
    Good morning Mr. Chairman, Ranking Member Miller and distinguished 
members of this subcommittee.
    I look forward to discussing the incidence of substance abuse and 
associated conditions plaguing our nation's veterans.
    Our servicemen and women put their lives on the line to ensure that 
our nation is safe and that our freedoms are protected.
    Unfortunately, the battle is not always over once these brave men 
and women return home.
    The stress of wartime service puts our returning troops and 
veterans at risk for mental illness such as PTSD and Substance Use 
Disorder.
    The rates of mental illness among service members are on the rise.
    It is likely that the demand for mental health services will 
continue to grow among soldiers returning from active combat.
    The 2007 National Survey on Drug Use and Health showed us that too 
many of our veterans suffer from Serious Psychological Distress and 
substance use disorder.
    I am eager to hear today's testimony from the experts in veteran 
healthcare that are present.
    I also look forward to your opinions regarding the legislation that 
addresses the issues we will discuss here today.
    Thank you, Mr. Chairman, for the opportunity to discuss these 
issues that so many of our veterans face on a daily basis.

                                 
                Prepared Statement of Patricia M. Greer
     President, NAADAC, the Association for Addiction Professionals
    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 healthcare 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\
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    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 healthcare.
    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\
---------------------------------------------------------------------------
    \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).
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \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+Te
am +(MHAT)+II+Brief&hl=en&ct=clnk&cd=1≷=us.
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    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.
Delivering Comprehensive Care
    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 acces
s to treatment.
    As this hearing's title aptly suggests, 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.
---------------------------------------------------------------------------
    \9\ National Institute on Drug Abuse. ``Principles of Drug 
Addiction Treatment: A Research Based Guide.'' NIH Publication NO. 00-
4180.
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    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 training 
to its addiction and mental health workforce.
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    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.

                                 
           Prepared Statement of Richard A. McCormick, Ph.D.
   Senior Scholar, Center for Health Care Policy and Research, Case 
               Western Reserve University, Cleveland, OH

    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 use disorder 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 10 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 as 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 are 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.

    References

    Biddle D, Hawthorne G, Forbes D, Coman G. Problem Gambling in 
Australian PTSD Treatment Seeking Veterans. Journal of Traumatic 
Stress, 18, 759-67, 2005.
    Daghestani AI, Elenz E, Crayton JW. Pathological gambling in 
hospitalized substance abusing veterans. Journal of Clinical 
Psychiatry, 57(8), 360-63, 1996.
    Gerstein, D.R., Volberg, R.A., Harwood, R., Christiansen, E.M., et 
al. 1999. Gambling Impact and Behavior Study: Report to the National 
Gambling Impact Study Commission. Chicago, IL: National Opinion 
Research Center at the University of Chicago. Kennedy CH, Jones DE, 
Grayson R. Substance abuse and gambling treatment in the military. 
Military Psychology, Clinical and Operational Applications. Guilford 
Press, 2006.
    Kausch O. Suicide Attempts Among Veterans Seeking Treatment for 
Pathological Gambling. Journal of Clinical Psychiatry, 64(9) 1031-1038, 
2003.
    Kim SW, Grant JE, Eckert D et al. Pathological gambling and mood 
disorders. Journal of Affective Disorders. 92, 109-116, 2006.
    McCormick RA, Russo A, Ramirez L, Taber JI. Affective disorders 
among pathological gamblers. American Journal of Psychiatry, 141, 215-
18, 1984.
    Miller MA & Westermeyer J. Gambling in Minnesota. American Journal 
of Psychiatry, 135(6), 845, 1996.
    Pallesen S, Mitsem M, Kvale G, et al. Outcome of psychological 
treatments of pathological gambling: A review and meta-analysis. 
Addiction, 100, 1412-22, 2005.
    Taber JI, McCormick RA, Russo, A et al. Follow-up of pathological 
gamblers after treatment. American Journal of Psychiatry, 144, 7575-61, 
1987.
    Weintraub D, Siderowf AD, Potenza MN, et al. The Association of 
Dopamine Agonist Use with Impulse Control Disorders In Parkinson 
Disease, Archives of Neurology, 63(7), 969-973, 2006.
    Westermeyer J, Canive J, Garrard J et al. Lifetime prevalence of 
pathological gambling among American Indian and Hispanic American 
Veterans. American Journal of Public Health, 95(5), 860-6, 2005.

                                 
                   Prepared Statement of Joy J. Ilem
  Assistant National Legislative Director, Disabled American Veterans
    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\
---------------------------------------------------------------------------
    \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.

      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\
---------------------------------------------------------------------------
    \2\ An Achievable Vision: The Report of the Department of Defense 
Mental Health Task Force, June 2007.

      Alcohol contributed to 65% of the markedly increased 
incidence of suicidal behavior in the military;\3\
---------------------------------------------------------------------------
    \3\ Ibid.

      In a recent study of returning National Guard, 24% 
reported alcohol abuse;\4\
---------------------------------------------------------------------------
    \4\ Wheeler, E. Self Reported Mental Health Status and Needs of 
Iraq Veterans in the Maine Army National Guard. Community Counseling 
Center, 2007 (unpublished).

      Reported rates of psychological problems increase with 
multiple deployments;\5\ and,
---------------------------------------------------------------------------
    \5\ An Achievable Vision: The Report of the Department of Defense 
Mental Health Task Force, June 2007.

      Reports of child abuse and increased incidence of marital 
problems in military families as a result of multiple deployments.\6\
---------------------------------------------------------------------------
    \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

    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 healthcare 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.
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \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)
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
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 healthcare 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.
---------------------------------------------------------------------------
    \11\ Department of Veterans Affairs National Mental Health Program 
Performance Monitoring System, Fiscal Year 2006.
---------------------------------------------------------------------------
    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\

    \12\ An Achievable Vision: The Report of the Department of Defense 
Mental Health Task Force, June 2007.
---------------------------------------------------------------------------
      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\

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

    \14\ United States Department of Veterans Affairs, Overview of 
Homelessness, March 6, 2008. http://www1.va.gov/homeless/page.cfm?pg=1.
---------------------------------------------------------------------------
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 healthcare 
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 healthcare and physical 
rehabilitation needs of veterans who served in OIF/OEF.
    DoD and VA share a unique obligation to meet the healthcare 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 healthcare 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.

                                 
             Prepared Statement of Thomas J. Berger, Ph.D.,
Chair, National PTSD and Substance Abuse Committee, Vietnam Veterans of 
                                America

    Mr. Chairman, Ranking Member Miller, distinguished members of this 
Subcommittee, and guests, Vietnam Veterans of America (VVA) thanks you 
for the opportunity to present our views on substance abuse and co-
morbid disorders. Foremost, Vietnam Veterans of America thanks this 
Subcommittee for your leadership in holding this hearing today on a 
most serious concern within our veterans' community.
    Each month hundreds of active duty troops, reservists and National 
Guard members return to their families and communities from deployment 
in Iraq and Afghanistan. Given the demanding and traumatizing 
environments of their combat experiences, many veterans experience 
psychological stresses that are further complicated by substance use 
and related disorders. In fact, research studies indicate that veterans 
in the general U.S. population are at increased risk of suicide.
    Moreover, according to the results of a national Survey on Drug Use 
and Health report issued by SAMHSA in November 2007, among veterans of 
the wars in Iraq and Afghanistan who received care from the Department 
of Veterans Affairs between 2001 and 2005, nearly one-third were 
diagnosed with mental health and/or psychosocial problems and one-fifth 
were diagnosed with a substance use disorder (SUD). Substance 
dependence or abuse includes such symptoms as withdrawal, tolerance, 
use in dangerous situations, trouble with the law, and interference in 
major obligations at work, school, or home during the past year. 
Individuals who meet the criteria for either dependence or abuse are 
said to have a SUD.
    In this NSDUH report, combined data from 2004 to 2006 indicate that 
an annual average of 7.0 percent of veterans aged 18 or older (an 
estimated 1.8 million persons annually) experienced serious 
psychological distress (SPD) in the past year. Veterans aged 18 to 25 
were more likely to have had an SPD (20.9 percent) than veterans aged 
26 to 54 (11.2 percent) or those aged 55 or older (4.3 percent). Female 
veterans were twice as likely as male veterans to have had an SPD in 
the past year (14.5 vs. 6.5 percent). And veterans with family incomes 
of less than $20,000 per year were more likely to have had an SPD in 
the past year than veterans with higher family incomes.
Substance Use Disorders
    The combined data from 2004 to 2006 also indicate that an annual 
average of 7.1 percent of veterans aged 18 or older (an estimated 1.8 
million persons) met the criteria for a SUD in the past year. One-
quarter of veterans aged 18 to 25 met the criteria for a SUD in the 
past year compared with 11.3 percent of veterans aged 26 to 54 and 4.4 
percent of veterans aged 55 or older. There was no difference in SUD 
between male and female veterans (7.2 vs. 5.8 percent). And veterans 
with a family income of less than $20,000 per year (10.8 percent) were 
more likely to have met the criteria for a SUD in the past year than 
veterans with a family income of $20,000 to $49,999 (6.6 percent), 
$50,000 to $74,999 (6.3 percent), or $75,000 or more (6.7 percent).
Co-occurring Disorders
    From 2004 to 2006, approximately 1.5 percent of veterans aged 18 or 
older (an estimated 395,000 persons) had a co-occurring SPD and SUD. 
Increasing age was associated with lower rates of past year co-
occurring SPD and SUD, with veterans aged 18 to 25 having the highest 
rate (8.4 percent) and veterans aged 55 or older having the lowest rate 
(0.7 percent). There was no significant difference in co-occurring 
disorders among males and females (1.5 vs. 2.0 percent, respectively). 
And veterans with family incomes of less than $20,000 per year were 
more likely to have had a co-occurring SPD and SUD in the past year 
than veterans with higher family incomes.
    These data can be summarized briefly below--
    Combined data from 2004 to 2006 indicate that an annual average of 
7.0 percent of veterans aged 18 or older experienced past year serious 
psychological distress (SPD), 7.1 percent met the criteria for a past 
year substance use disorder (SUD), and 1.5 percent had co-occurring SPD 
and SUD.
    Veterans aged 18 to 25 were more likely than older veterans to have 
higher rates of past year SPD, SUD, and co-occurring SPD and SUD. 
Veterans with family incomes of less than $20,000 per year were more 
likely than veterans with higher family incomes to have had SPD, SUD, 
and co-occurring SPD and SUD in the past year.
    And we must remember these data represent only those veterans who 
chose to seek help for their disorders from the VA. Vietnam Veterans of 
America has no reason to believe that the numbers cited above would not 
be higher if more of our OEF and OIF veterans were to seek VA care.
    The medical, social, and psychological toll from substance abuse 
disorders is enormous, both for the military and civilian sectors. In 
the face of such overwhelming damage, two questions emerge: Why does 
substance abuse receive relatively little medical and public health 
attention and support compared with other medical conditions? And what 
can be done to reduce the harm from substance abuse disorders?
    Despite their huge health toll, substance abuse disorders remain 
underappreciated and under-funded. Reasons include stigma, tolerance of 
personal choices, acceptance of youthful experimentation, pessimism 
about treatment efficacy, fragmented and weak leadership, powerful 
tobacco and alcohol industries, underinvestment in research, and 
difficult patients.
    Stigma: Despite emerging scientific evidence that substance abuse 
alters neurotransmitter patterns, many still stigmatize smokers, 
alcoholics, and drug abusers for having made unwise choices. They feel 
that even if central nervous system changes result from substance 
abuse, the choices were wrong in the first place. Another factor is the 
popular (and spurious) association of substance abuse with minorities. 
All too often, substance abuse is seen as having a black face, even 
though differences between blacks and whites in the prevalence of 
smoking and alcoholism and drug abuse do not support such stereotyping. 
Finally, public exposure to substance abuse can be polarizing, whether 
through secondhand smoke, raucous drunks, endangerment by an 
intoxicated driver, or encounters with aggressive alcoholic or drug-
abusing homeless persons.
    Civil liberties/free choice: A strong theme of U.S. culture is 
respect for choice and individual freedom. When the public health 
evidence is sufficiently compelling--such as with secondhand smoke or 
drunk-driving fatalities--regulatory measures can trump that civil 
libertarian tilt, but usually only after a long struggle.
    Tolerance of youthful experimentation: Most adults experimented in 
their youth with tobacco, alcohol, and drugs, and most drink 
responsibly as adults. They view these experiences as developmental 
rites of passage and may be unsympathetic to the minority who become 
addicted.
    Futility/hopelessness: The problems of substance abuse have been 
around so long that they seem to be intractable. In reality, there has 
been slow but impressive progress. U.S. smoking rates have declined 
since 2000, youth smoking is lessening, alcohol-related motor vehicle 
fatalities have fallen despite major increases in miles traveled, and 
the prevalence of illicit drug use has fallen.
    Pessimism about treatment efficacy: Public officials and clinicians 
share a double standard about treating substance abuse. Although they 
embrace aggressive treatment for diseases with miserable prognoses (for 
example, pancreatic cancer and malignant melanomas), they are skeptical 
about funding substance abuse treatment in which rates of one-year 
remissions may vary for smoking and for alcoholism and drug abuse. In 
clinical settings, this attitude is reinforced by clinicians' natural 
reluctance to encounter failures--smokers and drinkers who will not or 
cannot quit. One reason for this double standard is that substance 
abuse disorders are seen as volitional, while aggressive cancers are 
not. And recent data show declines in receipt of substance abuse 
treatment under private health insurance.
    Leadership: In contrast to breast cancer or HIV/AIDS, there are no 
aroused citizen advocacy groups for substance abuse disorders. The 
important exceptions of Mothers Against Drunk Driving and Students 
Against Drunk Driving and DARE stand as lone outliers to this rule. 
Undoubtedly, stigma makes it difficult for concerned groups to coalesce 
for public action. Even the most successful citizens group, Alcoholics 
Anonymous (AA), works undercover by design. Thus, there is no national 
``race for the cure'' against smoking-induced lung cancer and no 
national mobilized women's group fighting to stop alcoholism, smoking, 
or drug abuse.
    Fragmentation in the substance abuse field: Not only is there 
failure to coalesce among the three categories of substances, but even 
within each class there is rivalry, such as tensions between those who 
advocate for a twelve-step approach to drug and alcohol treatment and 
those who promote pharmaceutical treatment.
    Industries' power: The tobacco and alcohol industries spend 
billions on advertising and promotion, not to mention their 
contributions to political campaigns. These industries exert powerful 
political influence and have a track record of successful opposition to 
programs that would reduce use of their products. Investigators working 
to reduce harm from tobacco have been subjected to legal harassment, 
including suits requiring submission of voluminous primary data, 
depositions, and court testimony.
    Underinvestment in research: Despite the huge toll exerted by 
tobacco, only a small percent of the National Institutes of Health 
(NIH) budget is devoted to tobacco research. Similarly, the combined 
budgets of the National Institute on Drug Abuse (NIDA) and the National 
Institute on Alcohol Abuse and Alcoholism (NIAAA) amounted to $1.38 
billion in 2003, or less than 5 percent of total NIH expenditures.
    Difficult patients: Clinicians find it hard to care for patients 
with substance abuse problems. This reflects the limited education and 
training most clinicians receive on this topic and disappointment that 
so few patients follow their advice about quitting. At least in the 
case of drug-seeking behavior (when patients seek narcotics from 
physicians), the doctors may stop trusting these patients.
    Despite the obstacles noted above, VVA believes that a coordinated 
workable agenda within the military and the civilian population is 
possible to lessen the impact of substance use disorders. But this 
coordinated agenda must include the following--
    Better approaches to treatment: Adequate treatment for substance 
abuse is particularly challenging for America's uninsured. Even for the 
insured, many policies, including most Medicaid programs, do not cover 
the time for counseling or the costs of drugs such as nicotine 
replacement therapy and bupropion for smoking cessation, methadone for 
drug addiction, or disulfiram for alcoholism.
    As new, effective drugs come on the market, patients must have 
access to them. Clinicians and policymakers need to reframe how 
``successful treatment'' is defined. Physicians caring for patients 
with asthma or diabetes understand that these are chronic illnesses and 
that the goal is to maximize functioning and minimize disability. By 
contrast, many clinicians become frustrated because it is difficult to 
``cure'' smokers, alcoholics, or drug abusers. Rather than 
acknowledging that patterns of use often follow a waxing and waning 
course, that a year of sobriety is cause for triumph and social good, 
and that it may take many attempts before a patient is able to quit, 
they too often see the glass as half empty. Envisioning the goal of 
substance abuse treatment as managing chronic illness--including 
knowing appropriate referral sources within the community and the roles 
of non-physician professionals--could help doctors celebrate the 
tangible benefits of such treatment, instead of lamenting the reality 
that cures for most chronic diseases are often elusive. Drug courts, 
which offer treatment as an alternative to incarceration, are a 
promising but greatly underused resource.
    More support for research: Devote 20 percent of the current NIH 
budget to substance abuse research rather than the current amount. 
Beyond studying the basic science of addiction and exploring new 
pharmacologic treatments, research could help us understand why some 
people who experiment with substances become addicted while others do 
not, the comparative efficacy of different modes of treatment, the 
complexities of dual diagnosis (co-occurring mental illness and 
substance abuse), the social context of addiction, and the impact of 
various social policies on addiction and the harm it causes.
    Better education of health professionals: Substance abuse receives 
minimal notice in undergraduate and graduate medical education, 
specialty board certifying exams, continuing medical education, 
standard clinical textbooks, and medical journals. Not only is content 
slighted, but it is rare for medical education to acknowledge the role 
of other health professionals in treating substance abuse or the 
workings of twelve-step programs such as AA. This relative under-
emphasis reflects the reality that few medical faculty work in the area 
of substance abuse. The neglect is disappointing, given the extent to 
which substance abuse accounts for illness in Veterans Affairs (VA) and 
county hospitals--sites of intensive medical education for most 
academic medical centers.
    Nongovernmental funding: Although government will continue to 
provide the bulk of substance abuse treatment and research dollars, 
there are gaps in its funding. Some interventions--such as needle 
exchanges for heroin addicts as a way to reduce the transmission of HIV 
and hepatitis--may challenge strongly held ideological views, thus 
precluding government support. Also, the power of the tobacco and 
alcohol industries may deter adoption of proven public health 
strategies such as raising cigarette taxes or lowering the permissible 
blood alcohol level for drivers. Because there are areas where 
government either will not or cannot take a stand, private support 
matters. Examples are the role of the ACS and the Robert Wood Johnson 
Foundation in establishing the CTFK, the counter-marketing of the 
American Legacy Foundation and the Partnership for a Drug-Free America, 
and the Conrad N. Hilton Foundation's support for substance abuse 
educational programs in public schools.
    Stronger leadership needed: Greater recognition of substance abuse 
as a major health problem should encourage broader and more diverse 
leadership. Whether that leadership can or should transcend the 
individual substance categories is not clear. It may be that lumping 
together marijuana, beer, cigarettes, and heroin is too unwieldy to 
generate a unified constituency. Although substance abuse affects 
women's health, it has yet to surface on the advocacy agenda of the 
many women's organizations.
    Drug policies: Providing adequate treatment for community-based and 
incarcerated people with drug addiction generates social and medical 
savings: lower crime, lower prison spending, less family dysfunction, 
and better health. A RAND report of mandatory minimum sentences for 
cocaine concluded that dollar for dollar, treatment is fifteen times 
more effective than incarceration in reducing serious crime. Another 
study showed that treatment for substance abuse in criminal justice 
settings lowers re-incarceration rates. Also, providing clean needles 
for heroin addicts reduces the transmission of blood-borne diseases.
    Reform of the criminal justice system for substance abuse: Federal 
and state legislation imposes mandatory terms for possession of illicit 
drugs, thereby removing sentencing discretion from the hands of judges. 
Greater flexibility would reduce the cost and burden of incarceration 
and give many a chance for rehabilitation. Despite evidence that 
providing treatment and drug testing instead of incarceration can 
reduce both penal and social costs and increase the rate of drug 
rehabilitation, these approaches remain rare. Expansion will require 
permissive laws and knowledgeable judges. State corrections officials 
estimate that 70-85 percent of inmates need some level of substance 
abuse treatment. But in approximately 7,600 correctional facilities 
surveyed in 1997, less than 11 percent of the inmates were in drug 
treatment programs. Requiring substance abuse treatment as a condition 
of parole has been shown to increase treatment as well as abstinence 
from drug use.
    Substance abuse remains a serious medical, public health, and 
social problem. Yet it lacks champions, is underfunded, and is 
relatively neglected by clinicians and the medical establishment. 
Despite some real progress in the past decade, the United States still 
lags behind virtually every developed country in measures of health 
status. Our current national strategy to close that gap involves 
funding biomedical research to yield new treatments and improving 
access to care for
    Everyone, including America's veterans. Both are worthwhile goals 
but are doomed to failure unless they are coupled with effective 
policies to reduce harm from substance abuse.
    Thank you again for the opportunity to offer our views on this 
issue and I shall be glad to answer any questions.

                                 
                   Prepared Statement of Todd Bowers
   Director of Government Affairs, Iraq and Afghanistan Veterans of 
                                America

    Mr. Chairman, ranking member and distinguished members of the 
committee, on behalf of Iraq and Afghanistan Veterans of America, and 
our tens of thousands of members nationwide, I thank you for the 
opportunity to testify today regarding veterans' substance abuse.
    In particular, I would like to thank the committee for recognizing 
the issue of co-morbidity. As the committee knows, among the hundreds 
of thousands of troops returning from Iraq and Afghanistan with a 
mental health injury, a small but significant percentage is turning to 
alcohol or drugs in an effort to self-medicate. Veterans' substance 
abuse problems, therefore, cannot and should not be viewed as distinct 
from mental health problems.
    According to the VA Special Committee on PTSD, at least 30 to 40% 
of Iraq veterans, or about half a million people, will face a serious 
psychological injury, including depression, anxiety, or Post Traumatic 
Stress Disorder or PTSD. Data from the military's own Mental Health 
Advisory Team shows that multiple tours and inadequate time at home 
between deployments increase rates of combat stress by 50%.
    We are already seeing the impact of these untreated mental health 
problems. Between 2005 and 2006, the Army saw an almost threefold 
increase in ``alcohol-related incidents,'' according to the DOD Task 
Force on Mental Health. The VA has reported diagnosing more than 48,000 
Iraq and Afghanistan veterans with drug abuse. That's 16% of all Iraq 
and Afghanistan veteran patients at the VA. These numbers are only the 
tip of the iceberg; many veterans do not turn to the VA for help coping 
with substance abuse, instead relying on private programs or avoiding 
treatment altogether.
    Effective diagnosis and treatment of substance abuse is a key 
component of IAVA's 2008 Legislative Agenda. First and foremost, IAVA 
supports mandatory and confidential mental health screening by a mental 
health professional for all troops, both before and at least 90 days 
after a combat tour. Moreover, the VA must be authorized to bolster 
their mental health workforce in hospitals, clinics, and Vet Centers 
with adequate psychiatrists, psychologists and social workers to meet 
the demands of returning Iraq and Afghanistan veterans.
    The shortage of mental health professionals in the VA is hampering 
the effectiveness of mental health and substance abuse treatment. A VA 
Deputy Undersecretary has admitted that waiting lists render mental 
health and substance abuse care ``virtually inaccessible'' at some 
clinics. In October 2006, almost one-third of Vet Centers admitted they 
needed more staff. By April 2007, more than half of the 200-plus Vet 
Centers needed at least one more psychologist or therapist. As a result 
of the staffing shortage, veterans seeking mental health care get about 
one-third fewer visits with VA specialists now, compared to ten years 
ago. Veterans in rural communities are especially hard-hit. For 
instance, Montana ranks fourth in sending troops to war, but the 
state's VA facilities provide the lowest frequency of mental health 
visits.
    Effective treatment of veterans' mental health and substance abuse 
issues requires the real commitment of the Congress to fund an 
expansion of the corps of VA mental health professionals. But improving 
veterans' mental health care is not simply a legislative fix. That is 
why IAVA has partnered with the Ad Council, the nonprofit organization 
responsible for some of America's most effective and memorable public 
service campaigns, including ``A Mind is a Terrible Thing to Waste,'' 
``Only You Can Prevent Forest Fires,'' and ``Friends Don't Let Friends 
Drive Drunk.'' This summer, the Ad Council and IAVA will launch a 
multi-year campaign to de-stigmatize mental health care for service 
members and their families. The broadcast, print, web and outdoor ads 
will encourage those who need it to seek mental health care and inform 
all Americans that seeking help is a sign of strength rather than 
weakness. We are very excited to partner with Ad Council to help get 
troops, veterans, and their families the care they need and deserve.
    I thank you for providing me the opportunity to testify before you 
this afternoon. I would like to point out that my testimony today does 
not reflect the views of the United States Marine Corps. I am here 
testifying today in my civilian capacity as the Director of Government 
Affairs for Iraq and Afghanistan Veterans of America. All the data and 
IAVA recommendations I have cited are available in our Mental Health 
report and our Legislative Agenda. It would be my pleasure to answer 
any questions you may have for me at this time.
    Respectfully submitted.

                                 
             Prepared Statement of Antonette Zeiss, Ph.D.,
  Deputy Chief Consultant, Office of Mental Health Services, Veterans 
       Health Administration, U.S. Department of Veterans Affairs

    Mr. Chairman and members of the Subcommittee, I am pleased to be 
here today to discuss the ongoing steps that the Department of Veterans 
Affairs (VA) is taking to treat substance abuse and co-morbid 
disorders. I am accompanied by Mr. Charles Flora, Associate Director of 
Readjustment Counseling Service. Mr. Flora is a clinical social worker 
and Vietnam veteran, and has a lifetime of experience in readjustment 
counseling at both the Vet Center and national levels.
    Also accompanying me is Dr. John Allen, Associate Chief Consultant 
for Addictive Disorders. Dr. Allen is a national expert on substance 
use disorders and is a veteran of Operation Iraqi Freedom. His 
commitment to this work goes beyond the call of a doctor-patient 
relationship and echoes the pledge our service members make to one 
another. While VA has always taken the problem of substance use 
disorder (SUD) very seriously and has demonstrated our commitment to 
helping our veterans overcome this disease, we welcome Dr. Allen's 
personal connection to our returning veterans.
    We thank the Committee and you, Chairman Michaud, for your active 
interest in this topic. Tragically, substance use disorders are common 
in our society, as they are in many societies. As all of you know, the 
incidence of substance use among veterans tends to exceed that of 
comparable civilian populations. One study by Todd Wagner, et al. from 
2007 found veterans are more likely than non-veterans to report driving 
under the influence of alcohol, smoking daily, and using marijuana. In 
another study, by Dr. Charles Hoge and published in the New England 
Journal of Medicine in 2004, the number of respondents who admitted to 
using alcohol more than they intended increased seven percent among 
Army respondents after deployment to Iraq or Afghanistan. Alcohol and 
drug misuse are associated with a host of medical, social, mental 
health, and employment problems. Fortunately, these problems are 
treatable, and with treatment, the lives of our patients and their 
loved ones can be enriched.
    Since the implementation of the Mental Health Strategic Plan, VHA 
has dedicated more than $458 million to improve access and quality of 
care for veterans who present with SUD treatment needs. We have 
authorized the establishment of 510 new substance use counselors and 
plan to continue expanding SUD services throughout Fiscal Year 2008 (FY 
2008) and FY 2009. In FY 2008, for example, our mental health 
enhancement budget includes over $37.5 million for expanded SUD 
services. VA is developing plans to allocate medical care funds from 
the FY 2008 funding to hire even more new professionals, develop new 
programs, expand existing services, and create an appropriate physical 
environment for care by upgrading the safety and physical structure of 
inpatient psychiatry wards, as well as domiciliary and residential 
rehabilitation programs.
    VA has increased the number of intensive outpatient SUD programs 
and plans further expansion. This reflects the continued transition 
from inpatient care to more effective intensive outpatient care for 
treating substance abuse problems.
    These efforts will increase access to substance abuse services 
throughout VA.
    Whenever a veteran is seen by a VA provider, he or she is screened 
for PTSD, military sexual trauma, depression, and problem drinking. We 
recognize screening is only valuable if we act upon positive screens 
and follow-up in a timely manner, and we are committed to doing that.
    For those needing additional services, VA's outpatient and 
inpatient SUD programs are available; there are more than 220 programs 
in place, with more in development. Detoxification services may be 
offered in inpatient units such as medicine, psychiatry, or inpatient 
chemical dependency units, but the majority of patients requiring 
detoxification are managed on an outpatient or ambulatory basis. 
Following detoxification, substance use disorder patients are generally 
seen in outpatient specialty clinics. VA maintains extended care 
facilities, including 19 inpatient programs designed specifically to 
treat SUD patients for 14 to 28 days. Additionally, there are 44 SUD 
residential rehabilitation treatment facilities, 15 SUD compensated 
work therapy programs, and 19 SUD focused domiciliaries. We also offer 
mental health intensive case management, where teams of VA health care 
providers visit patients in their own living arrangements.
    Most SUD patients are treated once or twice a week in outpatient 
clinics, while others may require more intensive outpatient care for a 
minimum of four hours per day. Thirty-four of the intensive outpatient 
facilities have the capability of offering treatment five days a week, 
and telemedicine services are offered to patients living in remote 
sites. Veterans with serious mental illness in addition to SUD, are 
seen in specialized programs, such as intensive outpatient substance 
use disorder clinics, mental health intensive case management, 
psychosocial rehabilitation and recovery day programs, and work 
programs.
    Common elements of treatment for SUD include FDA-approved 
medications, employment of cognitive-behavioral therapies, 
incorporation of peer support groups (such as Alcoholics Anonymous), 
enlistment of the support of significant others, and linking the 
veteran to community services.
    Mental healthcare, including attention to SUD, is being integrated 
into primary care clinics, and we also are integrating mental health 
services into VA's Community Based Outpatient Clinics (CBOCs), VA 
nursing homes, and residential care facilities. Placing mental health 
providers in the context of primary care for the veteran is essential; 
it recognizes the interrelationships of mental and physical health, as 
well as providing mental healthcare at the most convenient and 
desirable location for the veteran.
    VA has allocated $57.6M over the last three years to expand the 
capacity of our Domiciliary and Residential Rehabilitation Treatment 
(DRRT) bed programs. This expansion relieves pressure on acute 
psychiatric and SUD beds, but more importantly, these Residential 
Rehabilitation programs provide a therapeutic placement for recovering 
patients in a longer term rehabilitation setting. They offer intensive 
therapy experiences, well beyond what is offered in acute inpatient 
programs, and thus are a more appropriate level of care for the 
veteran. VA funded eleven new DRRT programs between FY 2005 and FY 
2007, and during that same period, enhanced staffing for specialized 
services, like SUD treatment, in fifteen others.
    VA employs full and part time psychiatrists and full and part time 
psychologists who work in collaboration with social workers, mental 
health nurses, counselors, rehabilitation specialists, and other 
clinicians to provide a full continuum of mental health services for 
veterans. We have steadily increased the number of these mental health 
professionals over the last two and a half years. Currently, we have 
hired over 3,800 new mental health staff in that time period, for a 
total mental health staff of over 16,500. Appropriate attention to the 
physical and mental health needs of veterans will have a positive 
impact on their successful re-integration into civilian life.
    In addition to the care offered in medical facilities and CBOCs, 
VA's Vet Centers provide outreach and readjustment counseling services 
to returning war veterans of all eras. It is well-established that 
rehabilitation for war-related PTSD, SUD, and other military-related 
readjustment problems, along with the treatment of the physical wounds 
of war, is central to VA's continuum of healthcare programs specific to 
the needs of war veterans. The Vet Center service mission goes beyond 
medical care in providing a holistic mix of services designed to treat 
the veteran as a whole person in his/her community setting. Vet Centers 
provide an alternative to traditional mental healthcare that helps many 
combat veterans overcome the stigma and fear related to accessing 
professional assistance for military-related problems. Vet Centers are 
staffed by interdisciplinary teams that include psychologists, nurses 
and social workers, many of whom are veteran peers.
    Vet Centers provide professional readjustment counseling for war-
related psychological readjustment problems, including PTSD counseling. 
Other readjustment problems may include family relationship problems, 
lack of adequate employment, lack of educational achievement, social 
alienation and lack of career goals, homelessness and lack of adequate 
resources, and other psychological problems such as depression and/or 
SUD. Vet Centers also provide military-related sexual trauma 
counseling, bereavement counseling, employment counseling and job 
referrals, preventive healthcare information, and referrals to other VA 
and non-VA medical and benefits facilities.
    VA is currently expanding the number of its Vet Centers. In 
February 2007, VA announced plans to establish 23 new Vet Centers 
increasing the number nationally from 209 to 232. This expansion began 
in 2007 and is planned for completion in 2008. Fifteen of the new Vet 
Centers have hired staff and are fully open. Five Vet Centers have 
hired staff and are providing client services, but are operating out of 
temporary space while they finalize their lease contracts. The three 
remaining Vet Centers are actively pursuing and/or completing staff 
recruiting and lease contracting. They will all be open by the end of 
the fiscal year.
    To enhance access to care for veterans in underserved areas, some 
Vet Centers have established telehealth linkages with VA medical 
centers that extend VA mental health service delivery to remote areas 
to underserved veteran populations, including Native Americans on 
reservations at some sites. Vet Centers also offer telehealth services 
to expand the reach to an even broader audience. Vet Centers address 
veterans' psychological and social readjustment problems in convenient, 
easy-to-access community-based locations and generally support ongoing 
enhancements under the VA Mental Health Strategic Plan.
    Since hostilities began in Afghanistan and Iraq, the focus of the 
Vet Center program has been on aggressive outreach at military 
demobilization and at National Guard and Reserve sites, as well as at 
other community locations that feature high concentrations of veterans 
and family members. To promote early intervention, the Vet Center 
program hired 100 OEF and OIF veteran returnees to provide outreach 
services to their fellow combatants. These fellow veteran outreach 
specialists are effective in mitigating veterans' fear and stigma 
associated with seeking professional counseling services.
    From early in FY 2003 through the end of FY 2007, Vet Centers have 
provided readjustment services to over 268,987 veteran returnees from 
OEF and OIF. Of this total, more than 205,481 veterans were provided 
outreach services, and 63,506 were provided substantive clinical 
readjustment services in Vet Centers.
    VA's research program also demonstrates our commitment to providing 
the best care possible for veterans with substance use disorders. The 
VA Office of Research and Development (ORD) directly funds 
approximately 100 active research studies of addictive disorders, 
including basic biological mechanisms of dependence, abuse and relapse, 
as well as genetics of alcoholism, treatments of alcoholism, drug 
abuse, and nicotine addiction. Many of VA's most eminent scientists, 
including a large cadre of VA Research Career scientists and our 2004 
Middleton Awardee (VA's highest honor for medical research), are 
devoting their careers to further understanding and treating substance 
use disorders in the veteran population. ORD is also working closely 
with the National Institutes of Health, specifically the National 
Institute of Mental Health and the National Institute of Drug Abuse, to 
forge research collaborations on substance abuse co-morbidities with 
mental illness, such as PTSD.
    Substance use disorder is a real problem, and its manifestation 
along with other mental health conditions can lead to physical health 
concerns, difficulty readjusting to civilian life, and a host of other 
problems. One of VA's highest priorities is to reduce the impact of 
substance abuse and provide veterans with the care they need. Thank you 
for your time and for the opportunity to discuss this important issue 
with you. I would be happy to address any questions you may have.

                                 
                     Statement of Joseph L. Wilson
    Deputy Director, Veterans Affairs and Rehabilitation Commission, 
                            American Legion

    Mr. Chairman and Members of the Subcommittee:
    Thank you for this opportunity to present The American Legion's 
views on ``Substance Abuse/Co-Morbid Disorders: Comprehensive Solutions 
to a Complex Problem.''
    According to the Government Accountability Office (GAO), the 
Department of Veterans Affairs (VA) drastically reduced its substance-
use disorder treatment and rehabilitation services between 1996 and 
2006. The number of veterans receiving specialized substance abuse 
treatment services has since decreased by 18 percent. According to VA 
records, the total of mental health cases among war veterans grew by 
58% from 63,767 on June 30, 2006, to 100,580 on June 30, 2007. These 
mental health issues include Post Traumatic Stress Disorder (PTSD), 
drug and alcohol dependency and depression.
    VA's Antoinette Zeiss, Deputy Chief of Mental Health Services, 
acknowledged VA is seeing the increase (in mental health cases) and is 
preparing to deal with it. Mr. Chairman, these facts suggests a system 
that's experiencing an increase, which also warrants the appropriate 
increase in staffing, funding, and clinical inpatient, outpatient and 
outreach programs. As for the decrease of substance abuse treatment 
services, with the influx of veterans seeking treatment, the 
possibility of them falling through the cracks is heightening.
    The Diagnostic Statistical Manual IV (DSM) defines substance-use 
disorders as dependence or abuse of drugs or alcohol. When discussing 
treatment for veterans within PTSD clinics, the terminology, substance 
abuse, is included in the definition of substance-use disorders.
Post Traumatic Stress Disorder and Substance Abuse
    In veteran and population samples, substance-use disorders co-occur 
with Post Traumatic Stress Disorder (PTSD). Symptoms of PTSD include 
hyper-vigilance, irritability, outbursts of anger, sleeplessness and 
fatigue, and can be accompanied by alcoholism, depression, anxiety and 
substance abuse.
    VA has acknowledged some veterans with PTSD treat their own 
symptoms with alcohol and wind up with diagnoses related to drug abuse. 
VA also acknowledges when veterans screen positive for symptoms of 
PTSD, they are interested in whether or not these also veterans have 
accompanied problems, such as, problem drinking and other problems.
    According to VA, there was a time in the past when coexisting 
conditions may have been barriers to care, when it was difficult to 
treat patients with PTSD and substance abuse due to PTSD programs 
requiring veterans to be sober and substance-abuse programs requiring 
them to be stable. VA claims this no longer occurs due to evidence-
based strategies for beginning PTSD and substance abuse treatment 
simultaneously. One approach, the program titled, ``Seeking Safety,'' 
is being disseminated throughout the VA medical system.
H.R. 4053 Mental Health Improvement Act of 2007
    Section 102 includes provision of substance-use disorder treatment 
services at each VA Medical Center (VAMC) and Community Based 
Outpatient Clinic (CBOC). These services are as follows:

      short term motivational counseling;

      intensive outpatient care; relapse prevention;

      ongoing aftercare and outpatient counseling;

      opiate substitution therapy;

      pharmacological treatments aimed at reducing craving for 
drugs and alcohol;

      detoxification and stabilization; and

      other services as deemed appropriate.

    Section 103 recommends VA provide veterans either inpatient or 
outpatient care for a substance-use disorder and a co-morbid mental 
health disorder, and ensure that treatment for such disorders is 
provided concurrently by a team of clinicians with appropriate 
expertise.
    Section 104 calls for the enhancement of care and treatment for 
veterans with substance-use disorders and PTSD, which is to be carried 
out through a competitive allocation of funds to facilities of VA for 
the provision of care and treatment to veterans who suffer from the 
aforementioned. Section 104 further suggests usage of Peer Outreach 
programs to re-engage veterans of Operation Iraqi Freedom/Operation 
Enduring Freedom (OIF/OEF) who miss multiple appointments for treatment 
of PTSD or substance use disorder.
    Mr. Chairman, Congress and VA have acknowledged the appropriate 
treatment programs implemented to ensure inclusive treatment of 
substance abuse within the PTSD clinical environment. However, if 
studies are concluding a decline in treatment for substance abuse 
within the VA healthcare delivery system, this would suggest a gross 
lack of communication and outreach in which to ensure a high 
concentration of treatment, thereby maximizing the chance of the 
nation's veterans of slipping through the cracks, as well as continued 
substance abuse.
    The American Legion holds the position that veterans who succumb to 
self-medication caused by their service-connected disability, such as 
PTSD, are entitled to a level of compensation that reflects all aspects 
of their disability. We also urge Congress to support the 
aforementioned proposals of H.R. 4053, to include assessing and/or 
auditing the implemented programs throughout the VA healthcare delivery 
system to ascertain whether or not all veterans have access or are 
accessing these programs.
Conclusion
    As for programs and supporting regulations currently in place; the 
nation's veterans continue to be deprived of treatment for substance 
abuse secondary to PTSD, which suggests an interruption and or gap in 
comprehensive care that ensures adequate treatment. Not meeting this 
mark also implies incomplete treatment which further invalidates the 
term, ``full continuum of care'' for those who served this nation with 
honor.
    In addition, if proposals such as H.R. 4053 are required to 
heighten outreach, disseminate appropriate treatment, and reassure 
acknowledgement of the implementation of related programs throughout 
the entire VA population, thereby guaranteeing the nation's veterans 
receive specialty care within the PTSD clinical environment, we 
encourage execution of such proposals. The American Legion supports the 
consistency of treatment throughout the veteran population nationwide, 
to include clinical programs in VAMC's, CBOC's, Vet Centers and related 
VA facilities.
    Mr. Chairman and members of the Subcommittee, The American Legion 
sincerely appreciates the opportunity to submit testimony and looks 
forward to working with you and your colleagues to resolve this 
critical issue. Thank you.

                                 
       Statement of Hon. Jeff Miller, Ranking Republican Member,
Subcommittee on Health, and a Representative in Congress from the State 
                               of Florida

    Thank you, Mr. Chairman:
    The physical and mental demands of military service including 
exposure to combat trauma and balancing both military and family 
responsibilities make those who bravely defend our freedoms at a higher 
risk for developing substance use disorders.
    I am very concerned about recent reports showing substance use 
disorders may be rising, particularly among younger veterans, and that 
many of these veterans suffering with substance use disorders also have 
other co-occurring mental health problems.
    In recent years, the VA has made progress in screening veterans and 
expanding treatment programs for substance use disorders.
    Still, the stigma associated with the substance use disorders and 
limited access to comprehensive treatment in many rural areas, keep 
veterans, especially those with co-occurring disorders, from getting 
the help and care they need.
    Substance use disorders can be treated and recovery is possible. 
That is why it is critically important that we understand the nature of 
substance use disorder among our veterans and effectively break the 
barriers that prevent them from obtaining treatment services.
    Chairman Michaud and I have joined in a bipartisan effort in 
introducing the Veterans Substance Use Prevention and Treatment Act of 
2008.
    Our bill, H.R. 5554, would require each VA medical facility to 
provide ready access to comprehensive care for substance use disorders. 
Screening would be required in all settings, including primary care. 
Detoxification, intensive outpatient care, relapse prevention services, 
residential treatment, peer-to-peer counseling and marital and family 
counseling would be among the required services.
    The legislation will also direct VA to conduct a pilot program for 
Internet-based substance use disorder treatment for veterans of 
Operations Iraqi Freedom and Enduring Freedom (OIF/OEF).
    This new generation of veterans is comfortable with computer 
technology. This program will allow VA to utilize new and innovate ways 
to reach those in need and hopefully help overcome the stigma that can 
be a large barrier to care for many military personnel.
    Substance use disorders complicated by co-occurring mental 
illnesses are difficult to treat. Underscoring the need for VA to focus 
on early detection, the dissemination of best practices and 
implementing a full continuum of care throughout the VA system.
    I look forward to hearing from our witnesses today and working 
together to support effective treatment and empowering those veterans 
who develop a substance use disorder to overcome their condition and 
lead productive lives.
    I want to thank everyone that is here today for taking the time to 
be a part of this important hearing and yield back the balance of my 
time.

                                  
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