[Senate Hearing 113-680]
[From the U.S. Government Publishing Office]





                                                        S. Hrg. 113-680

                 OVERMEDICATION: PROBLEMS AND SOLUTIONS

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

                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                    ONE HUNDRED THIRTEENTH CONGRESS

                             SECOND SESSION

                               __________

                             APRIL 30, 2014

                               __________

       Printed for the use of the Committee on Veterans' Affairs


[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]




         Available via the World Wide Web: http://www.fdsys.gov
         
         
                                    ______

                         U.S. GOVERNMENT PUBLISHING OFFICE 

88-308 PDF                     WASHINGTON : 2015 
-----------------------------------------------------------------------
  For sale by the Superintendent of Documents, U.S. Government Publishing 
  Office Internet: bookstore.gpo.gov Phone: toll free (866) 512-1800; 
         DC area (202) 512-1800 Fax: (202) 512-2104 Mail: Stop IDCC, 
                          Washington, DC 20402-0001
                                 
         
         
         
         
         
         
         
         
         
         
         
         
         
                     COMMITTEE ON VETERANS' AFFAIRS

                 Bernard Sanders, (I) Vermont, Chairman
John D. Rockefeller IV, West         Richard Burr, North Carolina, 
    Virginia                             Ranking Member
Patty Murray, Washington             Johnny Isakson, Georgia
Sherrod Brown, Ohio                  Mike Johanns, Nebraska
Jon Tester, Montana                  Jerry Moran, Kansas
Mark Begich, Alaska                  John Boozman, Arkansas
Richard Blumenthal, Connecticut      Dean Heller, Nevada
Mazie Hirono, Hawaii
                    Steve Robertson, Staff Director
                 Lupe Wissel, Republican Staff Director
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                            C O N T E N T S

                              ----------                              

                             April 30, 2014
                                SENATORS

                                                                   Page
Sanders, Hon. Bernard, Chairman, U.S. Senator from Vermont.......     1
Burr, Hon. Richard, Ranking Member, U.S. Senator from North 
  Carolina.......................................................     3
Blumenthal, Hon. Richard, U.S. Senator from Connecticut..........     5
Isakson, Hon. Johnny, U.S. Senator from Georgia..................     5
Begich, Hon. Mark, U.S. Senator from Alaska......................    53

                               WITNESSES

Petzel, Robert, M.D., Under Secretary for Health, Veterans Health 
  Administration, U.S. Department of Veterans Affairs; 
  accompanied by Tracy Gaudet, M.D., Director, Office of Patient 
  Centered Care and Cultural Transformation and Peter Marshall, 
  M.D., Director of Primary Care Pain Management, Minneapolis VA 
  medical center:
    Impromptu question/answer....................................     7
    Oral statement...............................................     8
    Prepared statement...........................................     9
    Response to posthearing questions submitted by:
      Hon. Bernard Sanders.......................................    19
      Hon. Mark Begich...........................................    23
      Hon. Richard Blumenthal....................................    24
Coots, BG Norvell V., USA, Deputy Commanding General (Support), 
  U.S. Army Medical Command and Assistant Surgeon General for 
  Force Projection, Office of the Surgeon General, U.S. Army; 
  accompanied by COL Kevin T. Galloway, Director, Army Pain 
  Management Program, Rehabilitation and Reintegration Division..    24
    Prepared statement...........................................    26
    Response to posthearing questions submitted by:
      Hon. Bernard Sanders.......................................    32
      Hon. Richard Blumenthal....................................    34
      Hon. Mark Begich...........................................    35
Briggs, Josephine, M.D., Director, National Center for 
  Complementary and Alternative Medicine, National Institutes of 
  Health.........................................................    36
    Prepared statement...........................................    38
    Response to posthearing questions submitted by:
      Hon. Bernard Sanders.......................................    40
      Hon. Mark Begich...........................................    42
    Additional information.......................................    44
Kahn, Janet, Ph.D., Research Assistant Professor, Department of 
  Psychiatry, University of Vermont and Senior Policy Advisor, 
  Consortium of Academic Health Centers for Integrative Medicine.    60
    Prepared statement...........................................    63
Edlund, Mark, M.D., Ph.D., Senior Research Public Health Analyst, 
  Behavioral Health Epidemiology Program, RTI International......    97
    Prepared statement...........................................    99

                                APPENDIX

American Legion, The; prepared statement.........................   109
Ilem, Joy J., Deputy National Legislative Director, Disabled 
  American Veterans (DAV); prepared statement....................   112
Maffucci, Jacqueline A., Ph.D., Research Director, Iraq & 
  Afghanistan Veterans of America (IAVA); prepared statement.....   115
Citizens Commission on Human Rights International (CCHR); report.   117

 
                 OVERMEDICATION: PROBLEMS AND SOLUTIONS

                              ----------                              


                       WEDNESDAY, APRIL 30, 2014

                                       U.S. Senate,
                            Committee on Veterans' Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 10:05 a.m., in 
room 418, Russell Senate Office Building, Hon. Bernard Sanders, 
Chairman of the Committee, presiding.
    Senators present: Senators Sanders, Rockefeller, Begich, 
Blumenthal, Burr and Isakson.

          OPENING STATEMENT OF HON. BERNARD SANDERS, 
              CHAIRMAN, U.S. SENATOR FROM VERMONT

    Chairman Sanders. Let us get to work. Let me thank our 
panelists for being with us for a really important discussion 
about a significant issue.
    Within the veterans' community--and in fact, throughout our 
Nation both in the public sector and the private sector--we 
face a very serious problem of overmedication.
    The result of that overmedication is significant numbers of 
people treated in the Department of Defense facilities, VA 
facilities, and in the private sector become dependent upon 
those medications intended to help them and ease their pain. 
Pain is a huge problem in the country and how we treat that 
pain in the most effective way is really what we are discussing 
today.
    Some people who are treated with a whole lot of medication 
become addicted, and I think we all know what happens when 
people become addicted, in the worst cases some may end up 
losing their lives due to overdoses. In my State and throughout 
this country, this is a huge problem.
    This is a major issue that has been discussed on this 
Committee during the last year, and we are so glad we have such 
a distinguished panel with us today to help us examine this 
problem.
    But, before we get to this issue at hand, I did want to say 
a very brief word about another issue that has attracted a lot 
of attention in this country, and that is the developing 
situation at the VA medical center in Phoenix.
    As I think everyone in this room knows, some very, very 
serious allegations have been made regarding delays in health 
care access and, as a result, the possible deaths of veterans. 
I just want to make it very very clear that I take and this 
Committee takes these allegations extremely seriously; and we 
are going to do everything we can to get to the bottom of this 
story and get to the truth.
    Yesterday I spoke to the VA's acting inspector general, 
Richard Griffin. There is a thorough investigation being 
conducted by the VA IG in Phoenix and I have been assured by 
Mr. Griffin that he has the resources he needs to thoroughly 
investigate that situation.
    I expect that the inspector general's office will conduct 
its investigation thoroughly and provide this Committee with an 
objective analysis of these very serious allegations. And as I 
indicated the other day, it is my intention to hold a hearing 
on this issue once the inspector general's inquiry is complete.
    I want to make two brief points on this issue. First, we 
will get to the bottom of what has happened in Phoenix. We will 
reach conclusions based on an objective investigation of the 
facts, not TV reports but an objective investigation of the 
facts.
    Second, we should not let these allegations impugn the 
excellent work done throughout this country by hundreds of 
thousands of VA doctors, nurses, administrators, and staff at 
all levels, many of whom are veterans themselves or are closely 
related to veterans.
    I have been all over this country. I just came back from 
the VA facility in Minneapolis, MN, and my assessment is that 
we have some great people there doing great work.
    Additionally, a recent survey by the American Consumer 
Satisfaction Index, an independent consumer service survey, 
pointed out patient satisfaction is incredibly high within VA--
higher, perhaps, than the private sector. And I can tell you in 
Vermont--and I think this story is true all over this country--
that when veterans walk into the VA, they feel very good about 
the quality of care they get.
    And I do not want anything that is happening or may have 
happened in Phoenix to impugn the very good work done by people 
throughout this country.
    Getting back to the issue at hand, as a Nation, we must 
remember that for many veterans, chronic pain is a part of 
their daily life. According to VA data, the most common 
diagnosis among post-
9/11 veterans is musculoskeletal ailments, including joint, 
neck, and back disorders. Chronic pain is a common symptom of 
this cluster of conditions.
    VA research demonstrates greater than 50 percent of male 
veterans using VA primary care report instances of chronic pain 
and the prevalence of chronic pain may be even higher among 
women veterans.
    Therefore, options for managing chronic pain among our 
veteran population are paramount to improving quality-of-life 
and reintegration.
    Additionally, PTSD, along with other mental health 
diagnoses, such as depression and anxiety, are frequently 
diagnosed among our veterans. According to the most recent data 
from VA, more than 55 percent of our post-9/11 veterans have 
been diagnosed with some type of mental health disorder.
    Just as with chronic pain, it is critical these veterans 
receive the treatment they need and deserve. Oftentimes, 
opioids are used to treat both chronic pain and certain mental 
health disorders. While opioids can be quite effective in 
treating these conditions, they also come with significant risk 
which is what we are going to be discussing today.
    Therefore, it is critical that these medications are 
prescribed to the right patients, with careful monitoring and a 
clear understanding of proper usage.
    I would point out that Senator John Boozman of Arkansas has 
been one of those Senators here who has raised this issue and I 
think, as we all know, John has been in the hospital with a 
heart issue. I think I speak for the whole Committee in wishing 
him the very best of luck and returning to us as soon as 
possible.
    Senator Burr.

        STATEMENT OF HON. RICHARD BURR, RANKING MEMBER, 
                U.S. SENATOR FROM NORTH CAROLINA

    Senator Burr. Well, thank you, Mr. Chairman, and let me 
report for my colleagues that Senator Boozman is home. He did 
not have a heart attack. He had a problem with his aorta. It 
was not an aneurism. It was a genetic flap that had he not 
caught it and had they not been able to do a surgical graft on 
his aorta, he would not have survived like many Americans.
    But the report is good. He is home. He will be back with us 
hopefully soon with a few synthetic parts but I think that by 
all accounts those synthetic parts work every bit as good as 
the original.
    Mr. Chairman, thank you for this hearing and, as important, 
thank you to our witnesses for being here.
    Since the Chairman has talked about Phoenix, let me just 
say this. This is not the first issue on quality of care that 
faces the department, and one veteran death related to delays 
in care is one too many.
    I strongly believe that this Committee needs to hold 
aggressive oversight hearings into these issues that the 
department continues to struggle with, including long wait 
times for specialty care appointments, the misuse of wait 
lists, and the issues documented in the health care inspections 
conducted by the inspector general which, by my count, is now 
over 50 since January 2013.
    Even with all of these issues being publicly reported or 
included in the reports by the IG, this Committee has yet to 
hold a single oversight hearing on the quality of care veterans 
are receiving at the VA facilities.
    Mr. Chairman, I would fully support and urge you to hold 
those hearings.
    I say as it relates to Phoenix, I think the Chairman is 
right. Let us get as many of the facts as we can and not rely 
on what is publicly printed.
    But again, I point to the IG investigations from the past 
and suggest that it is the responsibility of this Committee to 
respond to some of the problems and to work with the VA, Dr. 
Petzel, as a partner. And I have never seen the agency shy away 
from trying to solve those quality of care issues.
    Now, turning to today's subject matter, the United States 
is facing an epidemic of prescription drug abuse. That is why 
it is important that we are here today to conduct oversight 
over the care of veterans who have chronic pain. It is critical 
that we ensure that VA is taking the necessary steps to address 
the overuse of certain medications and the potential risk of 
misuse and dual prescriptions.
    It has been estimated that as many as 50 percent of male 
veterans and as high as 75 percent of female veterans--OEF and 
OIF veterans--struggle with pain.
    The prevalence of chronic pain will likely increase as more 
servicemembers transition into the VA system. These numbers 
demonstrate the need for VA to provide quality pain management 
services to ensure veterans with chronic pain are able to live 
productive and healthy lives.
    According to the Centers for Investigative Reporting, 
between 2001 and 2012 the number of VA prescriptions within 
four opiate categories--including hydrocodone, oxycodone, 
methadone, and morphine--surged 270 percent. Additionally, 
during 2012, VA providers wrote more than 6.5 million 
prescriptions within those opiate categories.
    I found these numbers alarming, in combination with recent 
media reports that describe veterans with known and documented 
drug addictions who were still being prescribed these types of 
medications.
    I would just like to highlight a couple of stories. A 
veteran with PTSD who self-medicated using oxycodone and heroin 
who later struggled to become clean and sober, who is still 
struggling with PTSD and his addiction, now faces a new battle 
with the VA system which continues to prescribe him opiates 
even though his electronic health record documents his 
addiction and the subsequent detox provided by VA.
    Another veteran, while still on active duty, says he was 
injecting himself with an anti-inflammatory drug prescribed by 
military doctors. When he was treated by VA, they only 
responded to his pain by, ``loading him up on narcotics.'' This 
veteran goes on to make the following statement, ``There were 
better options to treat my pain, and those were not presented 
to me. The priority was treating me the fastest, seemingly 
least expensive way, and it was the most detrimental.''
    Now, I am not sure that this is the patient-centered or 
veteran-centric care that we constantly hear VA describing. 
Even in today's testimony from the Department we will hear, 
``care is increasingly personalized, proactive and patient 
driven.''
    If these stories reflect what VA believes is personalized, 
proactive, and patient driven, we have more problems to address 
than just the quality of care and long wait times.
    When it comes to the care we are providing to those who 
have sacrificed so much for our Nation, we cannot afford to get 
it wrong. This Committee needs to hold VA accountable to ensure 
they are providing world-class care.
    Right now, with the media reports and even VA's own 
research, I am not sure we are. Today VA will describe their 
policies, directives, and initiatives to ensure opiate 
therapies are prescribed to veterans in a safe manner. It is 
our obligation to hold VA accountable and to ensure that they 
are providing the highest standard of care to those who are 
already in the system.
    Mr. Chairman, I thank you for calling this hearing. I look 
forward to the witnesses' testimony which will enlighten us and 
the opportunity to follow up with questions.
    Chairman Sanders. Senator Burr, thank you very much.
    Senator Blumenthal.

             STATEMENT OF HON. RICHARD BLUMENTHAL, 
                 U.S. SENATOR FROM CONNECTICUT

    Senator Blumental. Thank you, Mr. Chairman.
    I want to thank our witnesses for being here and for your 
dedicated and hard work to the service of our veterans and our 
Nation; and thank you, Mr. Chairman and Ranking Member Burr for 
your comments.
    I want to join in expressing my very strong alarm about the 
reports from Arizona. If true, these reports indicate not only 
a betrayal of trust but also, very bluntly, violation of our 
criminal laws in shredding documents and obfuscating evidence 
that is important to protect the public trust.
    So, I hope that the inspector general will complete his 
report as quickly as possible to restore that trust and 
confidence in the integrity of our system.
    I want place in the record, Mr. Chairman, if I may, a 
request that we be informed as to what the time table is for 
completing that investigation because I very much share the 
Chairman's concern that this Committee has a obligation 
separately and independently of the inspector general, which 
has been articulated by the ranking member as well, that we 
uncover whatever the facts are here and make sure that we 
fulfill our responsibility. And I believe that if the inspector 
general's investigation lags that we should proceed 
independently.
    I agree that we should make use of the inspector general's 
investigation if it proceeds promptly but I think that we 
should require some kind of preliminary report to us as to what 
the claims are and what the preliminary findings are because 
the reports about a secret waiting list, and about neglect of 
care, and about disregard of the responsibility to provide that 
care are beyond alarming. They are truly angering.
    I want to also express my interest and concern about the 
subject matter of this investigation. I have seen in 
Connecticut, as we have around the country, an epidemic of 
overuse and abuse of these powerful pain killers and other 
prescription drugs. They are not only deeply concerning 
themselves, but they are potentially a gateway to other abuse 
such as heroin.
    We have seen in Connecticut and Vermont as well, Mr. 
Chairman, how these prescription drugs can be a gateway to 
heroin use and other drug abuses; and so, particularly when it 
comes to our veterans, we need to make sure that we do whatever 
possible to prevent this kind of overuse and abuse. I know that 
alternate care, which we will discuss today, is integral to 
that effort.
    Thank you very much, Mr. Chairman.
    Chairman Sanders. Thank you, Senator Blumenthal.
    Senator Isakson.

               STATEMENT OF HON. JOHNNY ISAKSON, 
                   U.S. SENATOR FROM GEORGIA

    Senator Isakson. Well, Chairman Sanders, thank you for 
calling this hearing. I want to echo the words of Ranking 
Member Burr, yourself, and Senator Blumenthal that the Arizona 
situation is troubling for all of us.
    I am glad we are going to get to the bottom of it. I hope 
we will do so as expeditiously as possible, and then I hope we 
can take action to help support VA in finding out where there 
is a problem, if there is one, and then correcting it.
    Dr. Petzel and I have become close friends over the last 8 
to 9 months because of incidences that neither one of us wish 
would have happened. His quick response in Atlanta has been 
greatly appreciated. His response at the VA hospital in Augusta 
has been greatly appreciated, and the fact that he is going to 
be visiting in the next week, I think this weekend, again is 
very much appreciated and his attention to those matters.
    The VA situation we had in Augusta 2 or 3 years ago: the 
concern about, sterilization of colonoscopy and endoscopy 
equipment, the difficulty that we had in Atlanta with the 
suicide situation and the postponement or untimely following of 
mental health patients; and now what has happened in Arizona 
should be a warning call for all of us.
    I believe we have 340,000 great employees at VA. They do a 
tremendous job; and as the Chairman and Ranking Member said, I 
am very proud of what they do. But if there is a growing 
culture that believes it does not matter or it is not as 
important or our care is not as important as we think it should 
be, we need to nip that in the bud and see to it VA is to every 
veteran and to this country what it was promised to and what it 
must be.
    I think it is important and incumbent upon this Committee 
to get to the bottom, wherever the facts lead us, and to get 
the leadership of VA to go with us so that hand-in-hand we can 
correct the inequities that are going on.
    My last point is this. Pharmaceutical therapy is a godsend 
in terms of pain, in terms of management of disease and other 
chronic ailments. But it also can interact inappropriately with 
other drugs for other ailments. It can also be overprescribed. 
It also can mask a greater problem, particularly with regard to 
mental health.
    This is a terribly important hearing today. I am not a 
person of medicine nor a person of science but I am familiar 
enough with what goes on in terms of drug abuse and one drug 
leading to another, that we cannot allow ourselves to take the 
easy way out in terms of pain management or therapy for our 
veterans.
    We need to always be looking for the long-term benefit of 
that veteran, not just the short-term easing of pain when we 
are prescribing the power opiates that we are talking about 
today.
    Thank you for calling this hearing, Mr. Chairman.
    Chairman Sanders. Senator Isakson, thank you very much for 
your very apt and important remarks. I agree with virtually 
everything you said.
    What I want to do now, if it is alright with the Committee, 
is to introduce our panelists, but I did want to give Dr. 
Petzel a minute or two to address concerns about Arizona. I 
want the main focus of this hearing to stay on overmedication 
while there is interest about what is happening in Arizona.
    Dr. Petzel, could you briefly give us your understanding of 
the situation there?
    Dr. Petzel. Thank you very much, Chairman Sanders.
    First of all, it is important to state that we do care very 
deeply about the care of every single veteran that we are 
privileged to serve. They have earned and they deserve the 
absolute highest quality care that we can provide.
    We take these allegations, as all of you do, very 
seriously. That is why we have asked the independent office of 
VA's IG to go there and do an objective, independent, complete 
review as to exactly what has occurred.
    We also sent, from VHA, a team to Phoenix early to review 
the appointment and scheduling processes, and I need to say 
that to-date we found no evidence of a secret list and we have 
found no patients who have died because they have been on a 
wait list.
    We think it is very important that the inspector general be 
allowed to finish their investigation before we rush to 
judgment as to what has actually happened in Phoenix.
    The other important point is that when an incident like 
this occurs, as with colonoscopies and mental health consults 
that were mentioned earlier, we conduct a thorough systemwide 
look which we are in the process of doing now with scheduling 
and wait lists, seeing if the alleged practices are not 
occurring at any one of our other 150 medical centers.
    If the allegations are true, they are absolutely 
unacceptable and we--if the inspector general does confirm and 
substantiate these claims--we are going to take swift and very 
appropriate action.
    The last point is that the veterans deserve to have full 
faith in their VA health care system. VA facilities are 
committed to transparency. We undergo multiple external and 
independent reviews and every year we are committed to ensuring 
our veteran community and the public that VA hospitals are safe 
and that the quality of care there is high.
    Finally, as has been mentioned by several of you, we do 
appreciate the hard work and the dedication of all of our 
employees. These people are committed to the person to 
providing, again, the best care possible to these veterans who 
have earned and who deserve that care.
    Thank you.
    Chairman Sanders. OK. Thank you very much, Dr. Petzel.
    I thought it was important we deal with that issue briefly. 
Now, let us focus on the issue at hand which is overmedication 
problems and solutions. In order to address that issue, we have 
two excellent panels.
    Our first panel will include Dr. Petzel, who is the Under 
Secretary for Health, Veterans Health Administration, 
Department of Veterans' Affairs; accompanied by Dr. Tracy 
Gaudet, who is the Director, Office of Patient Centered Care 
and Cultural Transformation. Dr. Peter Marshall, Director of 
Primary Care Pain Management at the Minneapolis VA medical 
center.
    Brigadier General Norvell V. Coots, Deputy Commanding 
General, U.S. Army Medical Command and Assistant Surgeon 
General for Force Projection, Office of the Surgeon General; 
and he is accompanied by Colonel Kevin T. Galloway, Program 
Director, Army Pain Management Program.
    We also have Dr. Josephine Briggs, Director of the National 
Center for Complementary and Alternative Medicine, National 
Institutes of Health.
    So, thank you all very much for being with us; and Dr. 
Petzel, you may begin.

 STATEMENT OF ROBERT PETZEL, M.D., UNDER SECRETARY FOR HEALTH, 
  VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS 
AFFAIRS; ACCOMPANIED BY TRACY GAUDET, M.D., DIRECTOR, OFFICE OF 
  PATIENT CENTERED CARE AND CULTURAL TRANSFORMATION AND PETER 
   MARSHALL, M.D., DIRECTOR OF PRIMARY CARE PAIN MANAGEMENT, 
                 MINNEAPOLIS VA MEDICAL CENTER

    Dr. Petzel. Good morning, Chairman Sanders, Ranking Member 
Burr, and the Members of the Committee.
    I want to thank you for the opportunity to participate in 
this hearing to discuss the Department of Veterans Affairs' 
pain management and opioid safety programs, our use of 
complementary and alternative medicine, and psychotropic drug 
safety. I am accompanied today by Dr. Gaudet as was mentioned 
earlier and by Dr. Peter Marshall.
    Before I begin, I want to express my joy at hearing that 
Senator Boozman is recuperating well. We wish him a speedy 
recovery and look forward to him participating again in the 
affairs of this Committee.
    Let me begin today by acknowledging all of our Nation's 
veterans who suffer from chronic and acute pain. The burden of 
pain on veterans is considerable. Studies say that more that 50 
percent of all veterans receiving care at the VA are affected 
by some type of chronic pain, much of it being musculoskeletal.
    Six elements of effective pain control include the safe and 
effective use of pain care to enhance the quality of life and 
the satisfaction of veterans that are living with chronic pain.
    VA's concept of safe and effective pain care follow these 
six essential elements. Education of veterans and family 
members about good pain care. Education of the treatment teams 
about good pain care. Developing non-pharmacological and self-
management approaches. Safe and evidence-based use of all 
interventions and medications including opioids. Developing 
effective modalities for bringing pain care, especially 
expertise, to the veteran when needed. And finally, monitoring 
pain care efficacy at both the individual veteran level and at 
the system level.
    VA recently developed and implemented an innovative opioid 
safety program. This program uniquely combines feedback to 
providers at facilities on their prescribing practices with 
education and training to ensure opioid pain medications are 
used safely, effectively, and judiciously across our entire 
system.
    The purpose of the initiative is to help ensure that pain 
management is addressed thoughtfully, compassionately, and 
safely. This initiative holds considerable promise for 
mitigating the risks of harm among veterans receiving long-term 
opioid therapy, for promoting provider competence and safe 
prescribing of opioids, and in promoting veteran-centered, 
evidence-based, coordinated, disciplined, multi-disciplinary 
pain care for chronic pain.
    For cases where veterans have developed problems with 
opioid abuse and addiction, VA offers effective evidence-based 
treatments for opioid use disorder. Intensive treatments 
consisting of options for evidence-based psychotherapy and 
effective pharmacological therapy for opioid use disorder is 
available at all of our VA medical centers to help facilitate 
veterans' recovery.
    Recognizing that psycho-pharmacological treatments for 
mental health conditions require on-going efforts in quality 
improvement, VA is implementing a psychosocial drug safety 
initiative.
    It addresses pharmacological treatments across the range of 
mental health conditions including PTSD, depression, 
schizophrenia, bipolar disorder, substance abuse disorder, and 
many other mental health conditions.
    This psychotropic drug initiative is designed to identify 
overuse, underuse, and inappropriate use of these drugs by 
reviewing provider prescribing habits, patient use, and 
providing feedback to providers about their use of these 
medications and education about the appropriate use when we do 
find that the use is inappropriate.
    Key leadership has identified as its number 1 strategic 
goal to provide veteran patients with personalized, proactive, 
patient-driven health care. This approach to health prioritizes 
the veteran and their values and partners with them to 
personalize the strategies to optimize their health, healing, 
and sense of well-being.
    Many of the strategies that may be of benefit extend beyond 
what we conventionally address or provide by the health care 
system. Integrative medicine, which includes complementary and 
alternative medicine, provides a framework that aligns with 
this goal of personalized, proactive, patient-drive care.
    There is a growing evidence for the effectiveness of non-
pharmacological approaches as part of a comprehensive plan for 
chronic pain. These include acupuncture, massage, chiropractic 
care, mindfulness meditation, exercise therapy, relaxation 
therapies, and yoga. These are all being increasingly made 
available to our veteran patients.
    Mr. Chairman, we know our work to improve veteran care 
through accessible, safe, and effective pain management service 
is an ongoing task and is not yet finished.
    However, we are confident that we are developing and 
implementing programs that are responsive to veteran needs. We 
appreciate your support in identifying and resolving these 
challenges as we find new ways to care for America's veterans.
    Mr. Chairman, this concludes my testimony. My colleagues 
and I are prepared to answer your questions.
    [The prepared statement of Dr. Petzel follows:]
 Prepared Statement of Dr. Robert Petzel, Under Secretary for Health, 
   Veterans Health Administration (VHA), U.S. Department of Veterans 
                                Affairs
    Good morning, Chairman Sanders, Ranking Member Burr, and Members of 
the Committee. Thank you for the opportunity to participate in this 
hearing and to discuss the Department of Veterans Affairs' (VA) pain 
management programs and the use of complementary and alternative 
medicine. I am accompanied today by Dr. Tracy Gaudet, Director of 
Office of Patient Centered Care & Cultural Transformation, and Dr. 
Peter Marshall, Director of Primary Care Pain Management.
    The challenges related to living with chronic pain and providing 
safe and effective pain care are by no means unique to Veterans and the 
VA health care system. As described in the 2011 Institute of Medicine 
(IOM) report, ``Relieving Pain in America: A Blueprint for Transforming 
Prevention, Care, Education, and Research,'' \1\ pain is a public 
health challenge that affects millions of Americans and is increasing 
in prevalence. Pain contributes to morbidity, mortality, and disability 
across our Nation and the costs of pain can be measured both in terms 
of human suffering as well as economic impact. The IOM estimated that 
chronic pain alone affects 100 million United States citizens and that 
the cost of pain in the United States is at least $560-$635 billion 
each year, which is the combined cost of lost productivity and the 
incremental cost of health care.
---------------------------------------------------------------------------
    \1\ Institute of Medicine. 2011. Relieving Pain in America: A 
Blueprint for Transforming Pain Prevention, Care, Education and 
Research. Washington, DC: The National Academies Press.
---------------------------------------------------------------------------
                        chronic pain in veterans
    The burden of pain on the Veteran population is considerable. We 
know that Veterans have much higher rates of chronic pain than the 
general population, with more than 50 percent of all Veterans enrolled 
and receiving care at VA affected by chronic pain.\2\ Chronic pain is 
the most common medical problem in Veterans returning from the last 
decade of conflict (almost 60 percent).\3\ Many of these Veterans have 
survived serious and at times catastrophic injuries frequently a result 
of road-side bombs and other blast injuries. These events can result in 
multiple physical traumas including amputations and spinal cord 
injuries as well as concomitant psychological trauma which can compound 
chronic pain concerns. Often these Veterans require a combination of 
strategies for the effective management of pain, which may include 
treatment with opioid analgesics. That makes pain management a very 
important clinical issue for VA. Further, the treatment of pain is 
highly complex, and in the recent past, health care providers have 
often been accused of undertreating the pain that patients suffer. 
Getting the balance right is a challenge that we continue to work 
toward.
---------------------------------------------------------------------------
    \2\ Gironda, R.J., Clark, M.E., Massengale, J.P., & Walker, R.L. 
(2006).. Pain among Veterans of Operations Enduring Freedom and Iraqi 
Freedom. Pain Medicine, 7, 339-343.
    \3\ Veterans Health Administration (2013). Analysis of VA health 
care utilization among Operation Enduring Freedom (OEF), Operation 
Iraqi Freedom (OIF), and Operation New Dawn (OND) Veterans. Washington, 
DC: Department of Veterans Affairs.
---------------------------------------------------------------------------
    In 2010, VA and the Department of Defense (DOD) published evidence-
based Clinical Practice Guidelines for the use of chronic opioid 
therapy in chronic pain. The guidelines reserve the use of chronic 
opioids for patients with moderate to severe pain who have not 
responded to, or responded only partially to, clinically indicated, 
evidence-based pain management strategies of lower risk, and who also 
may benefit from a trial of opioids to improve pain control in the 
service of improving function and quality of life.
    We also know that the long-term use of opioids is associated with 
significant risks, and can complicate health care for Veterans with 
Posttraumatic Stress Disorder (PTSD), depression, Traumatic Brain 
Injury (TBI) and family stress--all common in Veterans returning from 
the battlefield, and in Veterans with substance use disorders. Chronic 
pain in Veterans is often accompanied by co-morbid mental health 
conditions (up to 50 percent in some cohorts) caused by the 
psychological trauma of war, as well as neurological disorders, such as 
TBI caused by blast and concussion injuries. In fact, one study 
documented that more that 40 percent of Veterans admitted to a 
polytrauma unit in VHA suffered all three conditions together--chronic 
pain, PTSD, and post-concussive syndrome.\4\
---------------------------------------------------------------------------
    \4\ Lew, H.L., Otis, J.D., Tun, C., Kerns, R.D., Clark, M.E., & 
Cifu, D.X. (2009). Prevalence of chronic pain, Post Traumatic Stress 
Disorder, and post-concussive syndrome in OEF/OIF veterans: The 
polytrauma clinical triad. Journal of Rehabilitation Research and 
Development, 46, 697-702.
---------------------------------------------------------------------------
    In addition to these newly injured Veterans suffering from chronic 
pain conditions and neuropsychological conditions, VA cares for 
millions of Veterans from prior conflicts, who along with chronic pain 
and psychological conditions resulting from their earlier combat 
experiences, are now developing health concerns related to aging, such 
as cancer, neuropathies, spinal disease, and arthritis, all of which 
may be accompanied by chronic and at times debilitating pain. All of 
these Veterans deserve safe and effective pain care that may include 
the use of opioid analgesics when clinically appropriate.
    Thus, VA cares for a population that suffers much higher rates of 
chronic pain than the civilian population, and also experiences much 
higher rates of co-morbidities (PTSD, depression, TBI) and 
socioeconomic dynamics (family stress, disability, joblessness) that 
contribute to the complexity and challenges of pain management with 
opioids.\5\ So even as more Veterans have the kind of severe and 
disabling pain conditions that require stronger treatments such as 
opioids, so do more of them have increased risk for overdose 
complicated by depression, PTSD and substance use disorders.
---------------------------------------------------------------------------
    \5\ See citations 3 and 4.
---------------------------------------------------------------------------
    In recognition of the seriousness of the impact of chronic pain on 
our Veterans' health and quality of life, VHA was among one of the 
first health systems in the country to establish a robust policy on 
chronic pain management and to implement a system-wide approach to 
addressing the risks of opioid analgesia.
    I would like to at this time outline our approach to this pain care 
transformation. I will highlight VA's current pain management 
strategies as well as actions being taken to improve the management of 
chronic pain, including the safe use of opioid analgesics, the 
prevalence and use of opioid therapy to manage chronic pain in high 
risk Veterans, the challenges of prescription drug diversion \6\ and 
substance use disorders among Veterans, and efforts being made to 
broaden non-pharmacological approaches to pain care. I will also 
describe some of the best pain care practices across the VA health care 
system.
---------------------------------------------------------------------------
    \6\ Diversion is the use of prescription drugs for recreational 
purposes.
---------------------------------------------------------------------------
                         va's pain care mission
    VA's mission relative to pain care is simple: safe and effective 
pain care to enhance the quality of life and satisfaction of all 
Veterans living with chronic pain.
    VA's concept of safe and effective pain care includes the following 
six essential elements:

    1. Education of Veterans and family members about good pain care;
    2. Education of the treatment teams about good pain care;
    3. Developing non-pharmacological and self-management approaches;
    4. Safe and evidence-based use of all interventions and 
medications, including opioids;
    5. Developing effective modalities for bringing pain care specialty 
expertise to the Veteran; and
    6. Monitoring pain care efficacy at the individual and system 
level.

    As a blueprint for implementing these principles throughout the 
system,\7\ VHA Pain Management Directive 2009-053 \8\ was published in 
October 2009 to provide uniform guidelines and procedures for providing 
pain management care. These include standards for pain assessment and 
treatment, including use of opioid therapy when clinically appropriate, 
for evaluation of outcomes and quality of pain management, and for 
clinician competence and expertise in pain management. Since 
publication of the Pain Management Directive, a dissemination and 
implementation plan has been enacted that supports the following:
---------------------------------------------------------------------------
    \7\ The overall objective of the national strategy is to develop a 
comprehensive, multicultural, integrated, system-wide approach pain 
management that reduces pain and suffering and improves quality of life 
for Veterans experiencing acute and chronic pain associated with a wide 
range of injuries and illnesses, including terminal illness.
    \8\ www.va.gov/vhapublications/viewpublication.asp?pub_id=2781

     Comprehensive staffing and training plans for providers 
and staff;
     Comprehensive patient/family education plans to empower 
Veterans in pain management;
     Development of new tools and resources to support the pain 
management strategy; and
     Enhanced efforts to strengthen communication between VA's 
Central Office (VACO) and leadership from facilities \9\ and Veterans 
Integrated Service Networks (VISN).
---------------------------------------------------------------------------
    \9\ The term ``facilities'' or ``facility'' refers to VA's 151 
medical centers, hospitals, or health care systems.

    Following the guidance of the VHA National Pain Management 
Strategy, and in compliance with generally accepted pain management 
standards of care, the Directive provides policy and procedures for the 
improvement of pain management through implementation of the Stepped 
Care Model for Pain Management (SCM-PM), the single standard of pain 
care for VHA, central to ensuring Veterans receive appropriate pain 
management services. The Directive also requires tracking opioid use 
and implementing strong practices in risk management to improve 
Veterans' safety.
    To establish the six essential elements of good pain care listed 
above, numerous modalities have been recently implemented or are in the 
process of implementation throughout the VHA, including: pain schools, 
tele-pain schools, apps and web based modules for patient and family 
education; case based audio conferences, Rural Health Initiative and 
VeHU trainings, Nation-wide community of practice calls and numerous 
other training initiatives to educate and train teams; developing 
Cognitive Behavioral Therapy (CBT) in primary care, tele-CBT, self-
management strategies and complementary and integrative medicine 
modalities; a number of initiatives to address opioid prescribing which 
I will discuss shortly; e-consultation, Specialty Care Access Network-
Extension for Community Healthcare Outcomes (SCAN-ECHO), and 
telemedicine to bring pain care expertise to all settings; and pain 
dashboards to monitor care at the individual and populations levels.
    VA facilities are now increasingly leveraging their video 
conferencing capabilities to reach Veterans in the community based 
outpatient clinics (CBOC) both rural and highly rural to provide group 
and individual visits for pain schools, evidence based CBT, smoking 
cessation, and weight loss through the MOVE program all important for 
the self-care and self-management skills needed as part of a chronic 
pain care plan.
    A particularly exciting initiative is the development of a pain 
management application for smart phones that will be used by Veterans 
and their care partners to develop pain self-management skills. This 
tool, called VA Pain Coach, will eventually interface with VHA's 
Electronic Health Record (EHR), with appropriate privacy protections, 
allowing Veteran-reported information about pain, functioning, and 
other key elements in a secure mobile application environment to be 
securely stored and accessible to clinicians. VA Pain Coach, which is 
part of a suite of VA applications called ``Clinic in Hand,'' has just 
finished a one-year pilot test phase with 1150 Operation Enduring 
Freedom/Operation Iraqi Freedom/Operation New Dawn Veterans and their 
caregivers and is now being converted to HTML 5 and will be available 
for smart phones, tablets and as a web based application. In the 
future, a complementary initiative will build a clinician-facing 
application that will enhance the capacity of clinicians and Veterans 
to share in monitoring, decisionmaking, treatment planning, and 
reassessment of pain management interventions.
  the patient aligned care team (pact): the core of the stepped care 
                                 model
    The VA approach to pain care mirrors its approaches to all health 
care concerns: care is increasingly personalized, proactive and patient 
driven. Chronic pain, as is the case with all chronic health 
conditions, is most safely and effectively addressed using a 
biopsychosocial model in which all aspect of the Veterans health and 
well-being are included in both the assessment and management of the 
condition: physical health, psychological health and social health. The 
basic platform for providing such care is the Veteran's PACT, or 
patient aligned care team, supported by pain and other specialists. 
PACT is a partnership between the Veteran and the health care team, 
which emphasizes prevention, health promotion, and self-management. 
Veterans are the center of the care team and the PACT teamlet, which 
includes at its core a primary care provider, nurse care manager, 
clinical associate, and clerical associate. Core pain teams in PACT 
often add a behavioral health clinician and pharmacist to help address 
the complexity of pain management.
the pain medicine specialty team: specialty care access supporting pact
    PACT access to consultation and collaborative care with 
interdisciplinary pain specialty teams is critical. VHA's Pain Medicine 
Specialty Team Workgroup, chartered on January 26, 2012, provides 
standards for pain specialty care services and support of PACT pain 
management in the Stepped Care Model. Key areas of focus include the 
development of collaborative care models and participation in provider 
and team education through telehealth, e-consults, and SCAN-ECHO. VA 
SCAN-ECHO pain experts provide didactics and case-based learning to 
PACT members using videoconferencing technologies to strengthen the 
competencies of providers in pain management. More than 95 percent of 
VHA facilities have specialty pain clinics with documented yearly 
increases in use and capacity.
       vha pain management centers: developing and promulgating 
                            strong practices
    The complexity of managing chronic pain may require a more 
intensive and structured approach to care than can be provided in the 
primary care or specialty pain medicine clinics. To address the need 
for tertiary care pain services, on December 15, 2010, the VHA charted 
the Interdisciplinary Pain Management Workgroup to assist Veterans 
Integrated Service Network (VISN) Directors in determining the need for 
tertiary pain care and pain rehabilitation services. As of 
January 2014, VA has ten sites in seven VISNs with Commission on 
Accreditation of Rehabilitation Facilities (CARF)-accredited tertiary 
care pain rehabilitation programs, an increase from only 2 programs in 
2009, with 11 more sites in active preparation or actually applying for 
CARF status. These Centers have the capacity for providing advanced 
pain medicine diagnostics, surgical and interventional procedures, and 
in addition provide intensive, integrated chronic pain rehabilitation 
for Veterans with complex, co-morbid, or treatment refractory 
conditions.
    VHA is in process of greatly expanding access to such Chronic Pain 
Rehabilitation Centers. Pursuant to the expectation that every VISN 
shall have at least one CARF-accredited tertiary, interdisciplinary 
pain care program no later than September 30, 2014, the long-standing 
CARF Center at the James Haley Veterans Hospital in Tampa, one of only 
two multidisciplinary pain management centers that has been twice 
recognized by the American Pain Society as a Clinical Center of 
Excellence (the other being a program at Stanford University), has 
provided direct training to VISN teams from across VHA who wish to 
start CARF programs. Some VISNs may eventually have 2 or more such 
programs. In addition, there is an ongoing system-wide education 
effort, using the expertise at these Centers and in other facilities, 
to educate physicians in Primary Care PACT and other providers taking 
care of Veterans with chronic pain conditions about Chronic Pain 
Rehabilitation approaches.
               implementing the stepped care model in vha
    To help manage the implementation of the Stepped Care Model, VHA's 
National Pain Management Program Office (NPMPO) works closely with 
other VHA national offices such as pharmacy, mental health, and primary 
care. Other collaborations include NPMPO's partnership with Women's 
Health Services to develop a strategic plan to strengthen the capacity 
for women Veteran pain management services. NPMPO also relies on 
consultation with the interdisciplinary National Pain Management 
Strategy Coordinating Committee, consisting of members of all relevant 
clinical offices/programs in VHA, and meets regularly with all VISN 
Pain Points of Contact (POC). VISN POCs in turn meet regularly with 
Facility POCs in their VISN.
    The role of the Pain POCs, at the VISN and at the facility level, 
is primarily to coordinate efforts in regard to pain management from an 
administrative side. The Pain POCs are expected to work closely with 
the Pain specialists at each facility within the facility Pain 
Management Committee. This structure creates a two-way communication of 
successful `best practices' in the field, which are then communicated 
nationally, as well as advice and support on policy implementation. The 
Pain POCs are not the point of contact for clinical issues regarding 
individual patients. With regards to evaluation and treatment, a 
Veteran's clinical point of contact for their individual pain needs is 
their primary care provider within the PACT. As necessary, the pain 
medicine specialty team at the facility would work in collaboration.
                 stepped care model for pain management
    As mentioned earlier, SCM-PM is the single standard of pain care 
for VHA to ensure Veterans receive appropriate pain management 
services. Specifically, SCM-PM provides for assessment and management 
of pain conditions in the primary care setting. This is supported by 
timely access to secondary consultation from pain medicine, behavioral 
health, physical medicine and rehabilitation, specialty consultation, 
and care by coordination with palliative care, tertiary care, advanced 
diagnostic and medical management, and rehabilitation services for 
complex cases involving co-morbidities such as mental health disorders 
and TBI.
    In FY 2012, VHA made several important investments in implementing 
the SCM-PM. Major transformational initiatives support the objectives 
of building capacity for enhanced pain management in the primary care 
setting, including education of Veterans and caregivers in self-
management, as well as promoting equitable and timely access to 
specialty pain care services.
    There are other important efforts contributing to the 
implementation of SCM-PM in VHA facilities. Current initiatives focus 
on empowering Veterans in their pain management, and expanding capacity 
for Veterans to receive evidence-based psychological services as a 
component of a comprehensive and integrated plan for pain management. 
For example, during FY 2012, the VHA National Telemental Health Center 
expanded its capacity to deliver face-to-face, psychological services 
to Veterans remotely via high-speed videoconferencing links. This 
initiative not only emphasizes the delivery of cognitive behavior 
therapy for Veterans with chronic pain, but also promotes pain self-
management, leading to reductions in pain and improvements in physical 
functioning and emotional well-being.
    Additionally, a Primary Care and Pain Management Task Force is 
developing a comprehensive strategic and tactical plan for promoting 
full implementation of the SCM-PM in the Primary Care setting, and it 
continues to work on several products in support of this effort. For 
instance, the Task Force is continuing to expand its network of 
facility- level Primary Care Pain Management points of contact (Pain 
Champions) who meet monthly, via teleconference, to identity and share 
strong practices that have led to improved pain care in primary care 
settings.
    VA's pain management initiatives are designed to optimize timely 
sharing of new policies and guidance related to pain management 
standards of care. Of particular importance are VHA's continuing 
efforts to promote safe and effective use of opioid therapy for pain 
management, particularly those initiatives designed to mitigate risk 
for prescription pain medication misuse, abuse, addiction, and 
diversion.
                           opioid prescribing
    While opioid medications, due to their high risk to benefit ratio 
in chronic pain, will be playing a less prominent role in chronic pain 
management in the future, they are a primary focus currently due to the 
attendant risk of their use, particularly in individuals with some of 
the co-morbid conditions mentioned above.
    To monitor the use of opioids by patients in the VA health care 
system, VA tracks multi-drug therapy for pain in patients receiving 
chronic or long-acting opioid therapy for safety and effectiveness. 
This includes tracking of use of guideline recommended medications for 
chronic pain (i.e., certain anticonvulsants, tricyclic antidepressants 
(TCA), and serotonin and norepinephrine reuptake inhibitors (SNRI) 
which have been shown to be effective for treatment of some chronic 
pain conditions), and tracking of concurrent prescribing of opioids and 
certain sedative medications (e.g., benzodiazepines and barbiturates) 
which can contribute to over sedation and overdose risk when taken with 
opioids and the other medications for pain listed above.
    The prevalence of Veterans using opioids has been measured for 
Veterans using VHA health care services. For FY 2012, of the 5,779,668 
patients seen in VA, 433,136 (7.5 percent) received prescriptions for 
more than 90 days supply of short-acting opioid medications and 92,297 
(1.6 percent) received at least one prescription for a long-acting 
opioid medication in the year. Thus, since more than 50 percent of 
Veterans enrolled in VHA suffer from chronic pain, the most common 
condition in all Veterans, a relatively small percentage of those 
Veterans are receiving chronic opioid therapy, consistent with the DOD/
VA Clinical Practice Guidelines which limit their use to patients with 
moderate to severe persistent pain that has not responded to other 
safer alternatives that are clinically appropriate. Of these 525,433 
patients that received chronic or long-acting opioid therapy, 79,025 
(15 percent) were also prescribed a TCA, 90,066 (17 percent) were also 
prescribed an SNRI, and 178,361 (34 percent) were also prescribed an 
anticonvulsant some time in FY 2012.
    The co-prescription of either TCAs and SNRIs with opioids is first 
line therapy for the more severe cases of pain related to nerve damage 
from disease (e.g., diabetes, cancer) or from injuries (e.g., 
battlefield blast and projectile injuries with or without limb 
amputation and spinal cord injury). The numbers above suggest that 
clinical teams are using medically indicated combinations of 
medications that are specifically needed for these more severe 
conditions, which themselves are often co-morbid with musculoskeletal 
pain such as injuries to joints, spine and muscles. Of note, these 
prescriptions may or may not have overlapped with the opioid 
prescription during the year.
    Notably, 272,719 (52 percent) of patients on chronic or long-acting 
opioid therapy received non-medication-based rehabilitative treatments 
as part of their treatment plan (e.g., physical therapy (32 percent), 
chiropractic care (1 percent), programs to encourage physical activity 
(9 percent) or occupational therapy (17 percent), and 241,465 (46 
percent) also received behavioral or psychosocial treatment for chronic 
pain or co-morbid mental health conditions.
    These data, showing the use of non-medication treatments, suggest 
that Veterans are benefiting from VHA's efforts to create access to 
additional pain treatment modalities besides medication. This is 
consistent with VA's commitment to transform pain care to a 
biopsychosocial model \10\ that addresses all the factors that by 
research are demonstrated to affect Veterans' success in chronic pain 
treatment. Pursuant to this aim, a multimodality, team-based, stepped 
care model, per VHA Directive 2009-053, is being implemented widely 
throughout VHA, and in coordination with DOD.
---------------------------------------------------------------------------
    \10\ The Biopsychosocial Model takes the position that the causes 
and outcomes of many illnesses often involve the interaction of 
physical and pathophysiologic factors, psychological traits and states, 
and social-environmental factors. Effective treatment planning accounts 
for the salience of these factors in the precipitation and perpetuation 
of illness and illness-related disability.
---------------------------------------------------------------------------
    Opioid analgesics may help many patients manage their severe pain 
when other medications and modalities are ineffective or are only 
partially effective. However, there may be risks to both individual 
patients as well as to the surrounding community when these agents are 
not prescribed or used appropriately. VA has embarked on a two-pronged 
approach to addressing the challenge of prescription drug diversion and 
substance use disorders among Veteran patients. One approach is to 
improve the education and training in pain management and safe opioid 
prescribing for clinicians and the interdisciplinary teams that provide 
pain management care for Veterans. A complementary approach involves 
improving risk management through two systems initiatives.
                        opioid safety initiative
    VA recently developed and implemented an Opioid Safety Initiative 
(OSI) program to ensure opioid pain medications are used safely, 
effectively and judiciously. The Opioid Safety Initiative Requirements 
were issued to the VISN's on April 2, 2014. The purpose of the 
initiative is to ensure pain management is addressed thoughtfully, 
compassionately and safely. The nine goals are summarized below:

     Goal One: Educate prescribers of opioid medication 
regarding effective use of urine drug screening
     Goal Two: Increase the use of urine drug screening
     Goal Three: Facilitate use of state prescription databases
     Goal Four: Establish safe and effective tapering programs 
for the combination of benzodiazepines and opioids
     Goal Five: Develop tools to identify higher risk patients
     Goal Six: Improve prescribing practices around long-acting 
opioid formulations
     Goal Seven: Review treatment plans for patients on high 
doses of opioids
     Goal Eight: Offer Complementary and Alternative Medicine 
(CAM) modalities for chronic pain at all facilities
     Goal Nine: Develop new models of mental health and primary 
care collaboration to manage opioid and benzodiazepine prescribing in 
patients with chronic pain

    To do this, the initiative leverages the VHA's Electronic Health 
Record, making visible the totality of opioid use at all levels, 
patient, provider and facility, in order to identify high-risk 
situations. The OSI includes key clinical indicators such as the number 
of unique pharmacy patients dispensed an opioid, unique patients on 
long-term opioids who receive a urine drug screen, the number of 
patients receiving an opioid and a benzodiazepine (which puts them at a 
higher risk of adverse events) and the average dosage per day of 
opioids such as hydromorphone, methadone, morphine, oxycodone, and 
oxymorphone. Patients at risk for adverse events from use of opioids 
are identified through the use of administrative and clinical databases 
using pre-determined parameters based on published evidence and expert 
opinion. Providers whose prescribing practices are not aligned with 
medical evidence/strong practices are provided with counseling, 
education and support for to improve their care of Veterans with pain. 
Several aspects to measure the implementation of the Opioid Safety 
Initiative upon opioid use were underway at the time of the October 10, 
2013 hearing and suggested positive impacts:

     Despite an increase in the number of Veterans who were 
dispensed any medication from a VA pharmacy, (i.e., all pharmacy users) 
in October 2012 compared to November 2013, 39,088 fewer Veterans 
received an opioid prescription from VA during that time period.
     Performing urine drug screens is a useful tool to assist 
in the clinical management of patients receiving long-term opioid 
therapy. As of November 2013, urine drug screens were performed on 
80,294 more patients than in October 2012.
     Whenever clinically feasible, the concomitant use of 
opioid and benzodiazepine medications should be avoided. In 
November 2013, 9,609 fewer patients were receiving these drugs at the 
same time than in October 2012.
     Last, the average dose of selected opioids has begun to 
decline slightly in VA, demonstrating that prescribing and consumption 
behaviors are changing.

    While these changes may appear to be modest given the size of the 
VA patient population, they signal an important trend in VA's use of 
opioids. VA expects this trend to continue as it renews its efforts to 
promote safe and effective pharmacologic and non-pharmacologic pain 
management therapies. Very effective programs yielding significant 
results have been identified (e.g. Minneapolis, Tampa, Columbus), and 
are being studied as strong practice leaders.
    The second system-wide risk management approach to support the 
Veterans' and public's safety is promulgation of new regulations that 
enable VHA to participate in state Prescription Drug Monitoring 
Programs (PDMPs). VA providers can now access the state PDMP for 
information on prescribing and dispensing of controlled substances to 
Veterans outside the VA health care system. Participation in PDMPs will 
enable providers to identify patients who have received non-VA 
prescriptions for controlled substances, which in turn offers greater 
opportunity to discuss the effectiveness of these non-VA prescriptions 
in treating their pain or symptoms. More importantly, information that 
can be gathered through these programs will help both VA and non-VA 
providers to prevent harm to patients that could occur if the provider 
was unaware that a controlled substance medication had been prescribed 
elsewhere already.
       leveraging strong practices to change opioid prescribing: 
                the minneapolis va medical center (vamc)
    In summary, there is growing evidence of the successful 
implementation of a Stepped Care Model for Pain Management in VHA. 
Importantly, Veterans receiving long term opioid therapy for management 
of chronic pain are increasingly likely to be receiving this therapy in 
the context of multidisciplinary and multimodal care that often 
incorporates physical and occupational therapy and mental health 
services. All VISNs provide specialty pain clinic services, and the 
number of Veterans who receive these services has grown steadily for 
the past five years. Ten facilities now provide CARF accredited pain 
rehabilitation services, a rapid increase in the availability of these 
higher specialized pain rehabilitation services for our most complex 
Veterans with debilitating chronic pain and comorbid mental health 
disorders.
    VA learns from VISNs and VAMCs that are early adopters of 
implementing evidence-based guidelines and best practices. The 
Minneapolis VAMC has had great success with decreasing over utilization 
of opioid pain medications and developing a full range of pain 
management services. These efforts began with the Minneapolis VA Opioid 
Safety Initiative in 2011. Strong medical center leadership support led 
to the development of systems to identify patients on high risk opioids 
and provide team-based support from pharmacy, primary care, and mental 
health to develop individualized care plans to decrease high risk 
opioid use and improve patient safety. Implementing this best practices 
approach, Minneapolis has seen a nearly 70 percent decrease in high-
dose opioid prescribing for chronic non-cancer pain patients. This 
early success lead to a coordinated effort between Minneapolis VAMC and 
VISN 23 to expand support for PACT team-based pain management, Step 2 
pain consultation services, and rehabilitation focused 
multidisciplinary pain specialty services. The Minneapolis pain 
specialty services are now developing state-of-the-art, evidence-based 
interdisciplinary pain management programs and services, and also 
providing leadership, guidance, and support for primary care pain 
management throughout VISN 23 and VHA.
    VA is working aggressively to promote the safe and effective use of 
long-term opioid therapy for Veterans with chronic pain for whom this 
important therapy is indicated. VA's Opioid Safety Initiative holds 
considerable promise for mitigating risk for harms among Veterans 
receiving this therapy, for promoting provider competence in safe 
prescribing of opioids, and in promoting Veteran-centered, evidence-
based, and coordinated multidisciplinary pain care for Veterans with 
chronic pain. VA's Opioid Safety Initiative Tool provides monthly 
reports to all VISNs and facilities as to overall opioid prescribing an 
average dose per day of opioid therapy, which informs facilities of 
Veterans who are at risk for adverse outcomes and enables remedial 
steps to reduce those risks as described earlier by the Minneapolis 
VAMC. Interventions include VISN level, facility level and committees 
that provide support and education to improve the appropriate opioid 
risk mitigation for individual providers and facilities. Early evidence 
of success in reducing overall opioid prescribing and average dose per 
day of opioid therapy is encouraging.
                 complementary and integrative medicine
    VHA leadership has identified as its number one strategic goal ``to 
provide Veterans personalized, proactive, patient-driven health care.'' 
Integrative Health (IH), which includes CAM approaches, provides a 
framework that aligns with personalized, proactive, patient-driven 
care. There is growing evidence for effectiveness of non-
pharmacological approaches as part of a comprehensive care plan for 
chronic pain which includes acupuncture, massage, yoga and spinal 
manipulation. These are all being increasingly made available to 
Veterans.
    In 2011, VA's Healthcare Analysis and Information Group published a 
report on Complementary and Alternative Medicine in VA. At that time, 
89 percent of VHA facilities offered some form of CAM/IH; however, 
there was extensive variability regarding the degree, level, and 
spectrum of services being offered in VHA. The top reasons for offering 
CAM/IH included the following:

     Promotion of wellness;
     Patient preferences; and
     Adjunct to chronic disease management.

The most commonly offered CAM/IH modalities in VHA facilities were: 
Meditation, Stress Management/Relaxation Therapy, Progressive Muscle 
Relaxation, Biofeedback, and Guided Imagery. The conditions most 
commonly treated with CAM/IH include: Stress management, Anxiety 
Disorders, PTSD, Depression, and Back Pain.
    In VA, chiropractic care is part of the standard medical benefits 
and is administratively aligned under Rehabilitation and Prosthetic 
Services. The number of Veterans receiving chiropractic services in VA 
has expanded form under 4,000 in FY 2004, to over 26,000 in FY 2013. In 
addition to clinical services, Rehabilitation and Prosthetic Services 
is working to develop innovative approaches to foster chiropractic 
inter-professional education strategies and research projects.
    VA recognizes the importance and benefits of recreational therapy 
in the rehabilitation of Veterans with disabilities. Currently, over 30 
VA medical centers across the country participate in therapeutic riding 
programs. These programs use equine assisted therapeutic activities to 
promote healing and rehabilitation of Veterans with a variety of 
disabilities and medical conditions (e.g. Traumatic Brain Injury, 
polytrauma). VA facilities participating in such programs utilize their 
locally appropriated funds to support their participation. Facilities 
can also request supplemental support through the VA Secretary's 
General Post Fund, a trust fund administered by the Department to 
support a variety of recreational and religious projects and national 
rehabilitation special events.
    A monthly Integrative Health (IH) community of practice conference 
call provides VHA facilities national updates, strong practices, and 
new developments in the field and research findings related to IH.
    A key development is a Joint Incentive Fund DOD/VA project to 
improve Veterans' and Servicemembers' access to CAM, the ``Tiered 
Acupuncture Training Across Clinical Settings'' (ATACS) project. ATACS 
represents VHA's initiative to make evidence-based complementary and 
alternative medicine therapies widely available to our Veterans 
throughout VHA. A VHA and DOD network of medical acupuncturists are 
being identified and trained in Battlefield (auricular) Acupuncture by 
regional training conferences organized jointly by VHA and DOD. The 
goal of the project is for them to return to their facilities and VISNs 
with the skills to train local providers in Battlefield Acupuncture, 
which has been used successfully in DOD front-line clinics around the 
world. This initiative ultimately aims to provide all Veterans with 
access to this intervention, and a wider array of pain management 
choices generally, when they present with chronic pain.
                  integrative health--the way forward
    In late 2012, the Under Secretary for Health appointed a Team to 
review the organizational structure to support implementation of 
integrative health strategies in VHA. The Team recommended the 
expansion of the VHA Office of Patient Centered Care and Cultural 
Transformation's (OPCC&CT) capacity to develop and implement 
integrative health strategies in clinical activities, education, and 
research. OPCC&CT is now serving as the lead office in this work, 
expanding on existing efforts and with active partnerships across the 
organization. An Acting Director of VHA's Integrative Health 
Coordinating Center (IHCC) has been named and recruitment for core 
staff is in process. Additional staffing is being vetted now and that 
will continue until the program is fully developed.
    OPCC&CT has deployed a number of clinical, research, and education 
strategies to begin developing a more coordinated approach. This 
includes clinical pilots, work within the existing Centers of 
Innovations, and close alignment with the Office of Research and 
Development, as well as creating curricula and expanding education in 
these areas. VA's Evidence Synthesis program, in conjunction with 
OPCC&CT and Patient Care Services, is examining the scientific 
literature on various CAM modalities and presenting the findings in the 
form of an evidence map. At the present time, reviews are being done on 
Yoga, Tai Chi, and mindfulness meditation and a review was recently 
completed on acupuncture. The evidence map on acupuncture showed a 
positive effect of acupuncture on headaches, migraines, and chronic 
pain as well as a potential positive effect in multiple domains 
including depression and insomnia. The information from these reviews 
will help guide decision on how to best use CAM modalities within VA.
    The Whole Health Clinical Education Program, which includes an 
integrative health focus, launched last year, has received outstanding 
evaluation feedback from the clinicians and leadership who have taken 
the course. An online curriculum is under development and will have 
greater than 40 modules. These have been co-created with VA and the 
University of Wisconsin, leaders in the field of Integrative Medicine.
    Finally, the DOD/VA Health Executive Council (HEC) Pain Management 
Work Group (PMWG) was chartered to develop a model system of 
integrated, timely, continuous, and expert pain management for 
Servicemembers and Veterans. The Work Group participates in VA/DOD 
Joint Strategic Planning (JSP) process to develop and implement the 
strategies and performance measures, as outlined in the JSP guidance, 
and shares responsibility in fostering increased communication 
regarding functional area between Departments. The Group also 
identifies and assesses further opportunities for the coordination and 
sharing of health related services and resource between the 
Departments. A key development is the HEC PMWG's sponsoring of two 
Joint Incentive Fund projects to improve Veterans' and Servicemembers' 
access to competent pain care in the SCM-PM: the Joint Pain and 
Education Project (JPEP), and the ``Tiered Acupuncture Training Across 
Clinical Settings'' (ATACS) projects.
                      oversight and accountability
    Several key responsibilities are articulated in the Pain Management 
Directive. The Directive establishes a National Pain Management Program 
Office (NPMPO) in VACO that has the responsibility for policy 
development, coordination, oversight, and monitoring of VHA's National 
Pain Strategy. The Directive further authorizes the establishment of a 
multidisciplinary VHA National Pain Management Strategy Coordinating 
Committee that supports the Program Office in achieving its strategic 
goals and objectives. The Committee is comprised of 15 members to 
include: anesthesiology, employee education, geriatrics and extended 
care, mental health, neurology, nursing, pain management, patient 
education, pharmacy benefits management, primary care/internal 
medicine, quality performance, rehabilitation medicine, research, and 
women Veterans' health.
    The Directive requires VISN Directors to ensure that all facilities 
establish and implement current pain management policies consistent 
with this Directive. The NPMPO maintains records of VISN and facility 
compliance, along with other key organizational requirements contained 
in the Directive. All VISNs and facilities have appointed National Pain 
Office pain management points of contact, established multidisciplinary 
committees, and implemented pain management policies as required by the 
Directive. Health Care Provider Education and Training
    First, as recognized by the IOM in its extensive 2011 review, 
``Pain in America'' and the American Medical Association in its 2010 
Report on Pain Medicine \11\, and as articulated in VHA's Pain 
Management Directive in 2009-053, a formal commitment to pain 
management education and training for all appropriate clinical staff is 
required.
---------------------------------------------------------------------------
    \11\ Lippe P.M., Brock C., David J.J., Crossno R., Gitlow S. The 
First National Pain Medicine Summit--Final Summary Report. Pain Med 
2010;11(10):1447-68.
---------------------------------------------------------------------------
    The Joint Pain and Education Project, JPEP, mentioned earlier, has 
proposed training faculty in all VA training sites to pursue the 
implementation of such a curriculum; new generations of providers and 
other clinicians will themselves ultimately become the practitioners 
and teachers of good pain care. JPEP will target all levels of learner: 
the Veteran and his/her family and caregiver; the public; clinicians 
from all disciplines; specific providers and clinicians in practicing 
at each level of the SCM-PM: primary care, pain medicine specialty 
care, and other specialty care. VA is providing national leadership in 
developing interdisciplinary and discipline-specific competencies for 
pain management, in developing a system-wide approach to trainings, and 
in providing leadership roles in national projects to improve pain 
education and training.
                               conclusion
    Mr. Chairman, I would be the last person to say that we are now 
right where we want to be with our pain care in VA, but I will be the 
first person to say that we are well along in the process of getting 
there. I am confident that we will be setting standards for pain care 
nationally in the coming years. We are confident that we are building 
more accessible, safe and effective pain care that will be responsive 
to the needs of our Veterans and will better serve to enhance the 
quality of their lives. VA is committed to providing the high quality 
of care that our Veterans have earned and deserve, and we appreciate 
the opportunity to appear before you today. My colleagues and I are 
prepared to respond to any questions you may have.
                                 ______
                                 
Response to Posthearing Questions Submitted by Hon. Bernard Sanders to 
   Robert A. Petzel, MD, Under Secretary for Health, Veterans Health 
       Administration (VHA), U.S. Department of Veterans Affairs
                        opioid safety initiative
    Question 1.  How does VA plan to implement the Opioid Safety 
Initiative system-wide?
    Response. The Veterans Health Administration (VHA) has been 
vigorously pursuing implementation the Opioid Safety Initiative (OSI) 
to ensure optimal pain management and to safeguard Veterans from harm 
inherent in high-risk medications such as opioids and benzodiazepines. 
The objective of OSI is to make the totality of opioid use visible at 
all levels in the organization with a particular emphasis on 
identifying and remediating prescribing practices that place Veterans 
at increased risk for adverse outcomes. To this end, VHA has embarked 
on a system-wide program of education and training in pain management, 
opioid safety, access to alternative medical and non-medical treatments 
for pain, and patient education in self-management. These programs are 
manifestations of the core principles and policies outlined in the 2009 
Directive and are emphasized in the new draft Directive which is in 
development. In the meantime, Directive 2009-053 remains as VHA policy 
until replaced with the new Directive. To assist Veterans, providers 
and clinical teams in achieving OSI goals for safer opioid prescribing 
practices, an interdisciplinary VHA Task Force assembled a 15 module, 
peer-reviewed OSI Toolkit that is continually updated as new 
information becomes available, including new evidence-based practices. 
The OSI Toolkit is accessible to all VHA clinicians and disseminated 
widely and repeatedly through multiple communication channels and 
educational formats to facilitate safe opioid prescribing practices.
    a. What is the timeline for full implementation?
    Response. While The Opioid Safety Initiative (OSI) was launched in 
October 2013, it is an on-going endeavor, comprised of multiple inter-
disciplinary approaches, which will be constantly evaluated, modified 
and/or introduced to effective pain management and decrease the risks 
for complications due to both over- and under-treatment with opioids 
and other therapies. As an example, VHA OSI Task Force assembled a 15 
module, peer-reviewed OSI Toolkit that is continually updated as new 
information becomes available, including new evidence-based practices.

    Question 2.  What are the implications of the Opioid Safety 
Initiative beyond pain care, such as reducing the reliance of 
medications to treat mental health conditions?
    Response. VHA original response: The Opioid Safety Initiative 
addresses the risks of opioid analgesia comprehensively through a 
system-wide program with the following aims that include management of 
Veterans with co-morbid pain and mental health conditions:

     To reduce risks, such as high opioid doses, co-prescribing 
of benzodiazepines, close monitoring of Veterans with urine drug 
screens and Veterans with risks such as substance use disorders 
(addiction) and PTSD.
     To encourage the use of psychological, physical and 
complementary and alternative medicine (CAM) therapies such as 
acupuncture and yoga in pain management.
     To provide feedback and educational support for our 
clinical teams caring for patients with co-morbid pain and mental 
health disorders.

    Question 3.  How does VA plan to publicize this initiative--
particularly to veterans who may have avoided seeking treatment in the 
past because of concerns regarding medication?
    Response. VHA has embarked on a system-wide program of education 
and training in pain management, opioid safety, access to alternative 
medical and non-medical treatments for pain, and patient education in 
self-management. These programs are manifestations of the core 
principles and policies outlined in the 2009 Directive and are 
emphasized in the new draft Directive which is currently in 
concurrence. In the meantime, Directive 2009-053 remains VHA policy 
until replaced with the new Directive.

    Question 4.  One of the goals of the Opioid Safety Initiative is to 
facilitate use of state prescription databases. In which state 
prescription databases is VA able to participate? Is VA currently 
participating in all of the databases where it is able?
    Response. As of the date of this response, Prescription Drug 
Monitoring Program (PDMP) deployment is completed in 29 states, and is 
scheduled for completion in 6 more states by the end of August 2015. 
Please note that in 2 of these 6 states--Florida and Oregon--PDMP 
deployment is very near completion. In Florida, 4 of 6 sites are 
transmitting and in Oregon, 2 of 3 sites are transmitting. Deployment 
will occur in 13 other states by December 2016. The longer 
implementation period for these 13 states is due to their individually 
customized PDMP requirements that VA is working to satisfy. One state--
New Mexico--has advised the Department that it needs to purchase and 
install new software to support a PDMP, and that its timeline to 
accomplish this purchase is not yet determined. This issue affects all 
dispensing pharmacies within New Mexico. VA stands ready to activate 
the transmission of prescription drug data to New Mexico's PDMP system 
as soon as the state is ready. Missouri is the only state that has not 
enacted a PDMP law. The District of Columbia is currently developing 
its recently enacted PDMP. A complementary effort to PDMP deployment is 
the issuance of the VHA Directive, Querying State Prescription Drug 
Monitoring Programs, which we are planning to publish in the coming 
months. This Directive would establish policy requiring VHA health care 
provider participation in state PDMPs, consistent with applicable state 
laws. The Directive would assign responsibility to each facility 
Director to ensure that local policy and processes are established to 
support the Directive. Specifically, the Directive would outline when a 
query is needed, the frequency of a query, and any exclusions. 
Specifically, the draft would exclude any controlled substance 
prescription that is a 5 day supply or less without refills and any 
patient who is enrolled in Hospice care, unless required by state law.
              complementary and alternative medicine (cam)
    Question 5.  VA offers a number of CAM therapies, but they are not 
necessarily evenly distributed across the system and veterans are not 
always aware of what's available to them. What is VA doing to more 
evenly distribute access across the system? What is VA doing to inform 
veterans their options for CAM therapies? What is VA doing to encourage 
providers to offer these therapies and how is this being tracked?
    Response. VA is committed to offering Veterans more personalized, 
proactive and patient driven care. This entails better understanding of 
the needs and desires of Veterans and addressing their health care 
goals in a more holistic fashion. VHA has established an Integrative 
Health Coordinating Center whose mission is to help evaluate and where 
appropriate help integrate Complementary and Integrative Health (CIH) 
services into VA. In addition, the Office of Patient Centered Care and 
Cultural Transformation (OPCC&CT) has developed education on Whole 
Health, which is being disseminated throughout VA. These courses 
educate providers on how to approach healthcare in a more holistic 
fashion and educates them on CIH practices and how these may be able to 
play a part in Veterans healthcare. This education on CIH practices 
will expand the resources available to providers when they engage their 
patients in identifying their healthcare goals and the strategies they 
wish to embark on to attain these goals. As VA offers personalized, 
proactive, patient-driven care it is through educating providers that 
we work to ensure that Veterans have a discussion with their provider 
and discuss the best treatment option including all appropriate 
therapies including indicated CAM/CIH which is unique to the Veteran 
and their circumstance. VHA's educational programs for clinical staff 
are being disseminated in the field. These clinical courses educate 
providers on how to approach health care in a more holistic way and 
educates them on CAM therapies available. Other efforts are underway to 
provide information to Veterans. One example is that OPCC&CT developed 
an internet site as the focal point for messaging, resource delivery, 
and community engagement for the patient centered care body of work and 
the Veteran-facing products developed to educate and communicate with 
Veterans. Through the Health for Life site, we are providing products 
that enable Veterans to achieve their greatest health and well-being. 
OPCC&CT has also trained field implementation teams that are being 
deployed around the country to work with local leadership to create a 
culture that supports a whole health, patient-centered model inclusive 
of CIH services. They have developed an education campaign that 
includes both internal and external customer facing modules describing 
the new models of care and services that focus on putting the patient 
at the center of their care to create a personalized, proactive, 
patient-driven model.

    Question 6.  What factors limit VA from further broadening CAM 
therapies across the VA Health Care System?
    Response. The medical benefits package states that VA may offer 
those services that are in accord with generally accepted standards of 
medical practice. There are a vast number of Complementary and 
Integrative Health (CIH) practices, but the evidence base for many of 
them is limited. Questions remain about the efficacy of many of these 
practices, who responds to them, how they should be used, and for how 
long. Although no CIH practice is the gold standard for care, several 
practices show promise as adjuncts to care. In addition, many CIH 
practices lack standardized education, training, certification and 
licensure standards. These factors, combined with a lack of 
occupational classes for CIH practitioners within VA, pose significant 
barriers to the hiring of such providers within VA.
                          dod/va collaboration
    Question 7.  What benefits has VA seen from the standardization of 
the prescription medication between VA and DOD available to both 
servicemembers and veterans? Are servicemembers able to continue their 
existing course of treatment as they transition to VA health care?
    Response. Yes, Servicemembers are able to continue their existing 
course of treatment as they transition to VA health care, unless a 
change would be warranted based on a VA provider's clinical assessment 
(i.e., drug is no longer effective, patient's changing medical 
condition warrants a change, drug is no longer safe given clinical 
circumstances, etc.). There have been widespread anecdotal reports of 
Servicemembers' mental health and pain medications being switched due 
to differences between the VA and DOD drug formularies. However, these 
anecdotes were not substantiated in a medication continuity pilot 
evaluation of over 2,000 Servicemembers recently conducted by VA. In 
this pilot evaluation, VA found that 99% of patients receiving a mental 
health or pain medication were able to continue those medications 
despite differences between the VA and DOD formularies. The data from 
VA's pilot evaluation validates VA's long standing practice of 
continuing medication therapy started by Department of Defense 
prescribers. See (http://www.pbm.va.gov/PBM/
vacenterformedicationsafety/othervasafetyprojects/DOD--VA--Medication--
Continuation--Report.pdf).

    Question 8.  What other efforts have DOD and VA taken to 
collaborate and standardize treatment options for servicemembers and 
veterans for the treatment of chronic pain and mental health 
conditions?
    Response. The DOD/VA Health Executive Council's Pain Management 
Work Group ( HEC PMWG), which meets monthly, was chartered in 2010 to 
``actively collaborate in supporting the development of a model system 
of integrated, timely, continuous, and expert pain management for 
Servicemembers and Veterans.'' The HEC PMWG has articulated 6 
objectives for its present work:

    Objective 1--Standardize Pain Measurement. The PMWG has sponsored 
the development of the Defense and Veterans Pain Rating Scale to 
improve the measurement of pain. The tool has been validated and 
published, is in use in multiple military facilities and in civilian 
hospitals. Additional validation studies continue in DOD and VHA.
    Objective 2--Develop a clinical pain support tool and pain data 
registry. The PASTOR tool, incorporating the NIH ``PROMIS'' patient 
report outcome measures and computer adaptive testing, is under 
development and is being piloted in a collaboration between Madigan 
Army Hospital, NIH, and the University of Washington.
    Objective 3--Standardize Suboxone (buprenorphine and naloxone) 
Prescribing Practices. A common guidance document is developed and VHA 
and DOD working implementation in each organization.
    Objective 4--Develop Medical Drug Testing guidance. The PMWG 
developed DOD/VHA core guidance and have developed and share clinical 
education and training in JPEP modules and in the Opioid Safety 
Initiative Toolkit.
    Objective 5--Develop Acupuncture Credentialing guidance. The PMWG 
developed shared DOD/VHA core guidance for VHA and DOD clinicians and 
is working implementation of core guidance within their respective 
organizations
    Objective 6--Develop Informed Consent for Long-term Opioid Therapy. 
The VHA developed and approved a patient education document, ``Taking 
Opioids Responsibly,'' to assist in the informed consent process, and 
the DOD is evaluating the VHA document for implementation in DOD.

    Currently there are two Joint Investment Fund (JIF) supported 
projects to improve the competencies of our workforce across both 
systems:

     The Joint Pain Education and Training Project (JPEP).
         - Has developed 35 optional evidence-based training modules in 
        pain management for use in its multiple pain education programs 
        to help standardize pain management education and training 
        across the two health systems and to support and educate 
        clinicians and Veterans about safe and effective stepped pain 
        management, including use of opioids.
         - JPEP modules are being used for primary care residency 
        training and for practicing clinicians and clinical teams being 
        trained by the Pain Mini-residency, Pain SCAN ECHO, 
        asynchronous web-based courses, and Community of Practice 
        conferences.
         - All these programs reach across the VHA to train primary 
        care providers in all settings in the assessment and treatment 
        of pain and in the use of patient education in self-management, 
        the use of multiple modalities such as behavioral, integrative 
        medicine, and physical therapies and the use of consultant 
        specialists in pain, mental health, and CAM.
         - On the topic of opioids safety, for example, these programs 
        have presentations on universal precautions and risk 
        management, including clinical evaluation, written informed 
        consent, screening such as urine drug monitoring, use of state 
        prescription monitoring programs, and safe tapering.

     The Tiered Acupuncture Training Across Clinical Settings 
(ATACS)
         - Has trained more than 1290 front-line providers in the VA 
        and DOD in Battlefield Acupuncture as well as dozens of 
        physicians in medical acupuncture.
         - Represents VHA's initiative to make evidence-based 
        complementary and alternative medical therapies widely 
        available to our Veterans throughout VHA.
         - Provides Veterans with a wider array of pain management 
        choices when they present with chronic pain.
                          acupuncture training
    Question 9.  How would the Joint Incentive Fund Project to 
implement a standardized acupuncture training and sustainment model 
across DOD and VA medical facilities improve acupuncture services VA 
provides veterans? When can we expect system-wide implementation of 
this joint model?
    Response. By providing standardized training in the short course 
for Battlefield (auricular) Acupuncture (BFA) to hundreds of providers 
across the system, and by credentialing trainees to add BA to their 
pain management toolbox, these providers will be able to use this 
treatment as one of many they have to offer Veterans with pain. The 
physicians being trained in Medical Acupuncture will also be trained as 
BFA Faculty, so they can train their local facility providers in BFA to 
sustain the program's development system-wide.

    Question 10.  How many providers are trained in acupuncture already 
working in the VA Health Care System? How many of these providers are 
exclusively providing acupuncture? What is the average number of hours 
each provider trained in acupuncture offers this therapy each week?
    Response. We do not have information on the number of providers 
based at facilities who provide acupuncture or how many hours a week 
therapy is provided. However, from the 2015 Healthcare analysis and 
information group survey on VA Complementary and Integrative Health 
practices, we do know that 79 facilities offer acupuncture services 
primarily performed by physician-trained acupuncturists as a part of 
their duties at least a half day per week up to several times a week.

    Question 11.  What efforts are being made to ensure an adequate 
number are available to treat veterans once the joint model is 
implemented?
    Response. At the current time, physicians and chiropractors are the 
only VHA occupations with scopes of practice that include acupuncture. 
As a result, the availability of trained acupuncture providers within 
VA is limited. VA continues to support the training of physicians in 
acupuncture, but is also pursuing the development of a licensed 
acupuncturist occupational class within VHA. The addition of licensed 
acupuncturists to VHA occupations will expand VHA's ability to hire 
trained acupuncture providers.
                       pain management directive
    Question 12.  On October 28, 2009, VA issued the Pain Management 
Directive to improve VHA's processes for treating and managing chronic 
pain. How has system-wide implementation of the National Pain 
Management Strategy--as required by the Pain Management Directive--
improved VA's approach to pain management?
    Response. The implementation of Stepped Care has increased 
resources for primary care pain management, such as behavioral health 
clinicians, access to CAM, access to multidisciplinary pain specialty 
clinics, and access to tertiary care Commission on Accreditation of 
Rehabilitation Facilities (CARF) rehabilitation programs.

    Question 13.  Does VA plan to extend the Pain Management Directive? 
If not, please explain why not. If so, please explain whether it will 
be extended in its current form or if changes will be made.
    Response. Yes, a new Directive has been drafted and is undergoing 
VHA Concurrence. Until which time the new Directive is approved, the 
current Pain Management Directive will remain in effect.
                                 ______
                                 
  Response to Posthearing Questions Submitted by Hon. Mark Begich to 
   Robert A. Petzel, MD, Under Secretary for Health, Veterans Health 
       Administration (VHA), U.S. Department of Veterans Affairs
    Question 14.  My office has received casework from veterans who 
have severe PTSD issues that affect their day to day life, and say I 
quote ``I'm pretty much done with medications.'' They have asked for 
Hero Dogs, who raise and train service dogs and places them free of 
charge with our Nation's Veterans to improve quality of life and 
restore independence. Veterans with disabilities have given enough.
    Tell me what the VA is doing with expanding service/therapy dogs; I 
think this would be a cheaper option and a safer option rather than 
treating with opioids and other drugs.
    Response. Veteran preference is an important consideration when 
choosing a therapeutic approach to treat PTSD. Effective cognitive 
behavioral therapies are made available to every Veteran who seeks VA 
care for PTSD. VA is currently attempting to find ways to increase 
Veteran engagement with these treatment modalities and increase the 
likelihood that Veterans remain in treatment until remission or 
significant clinical improvement is accomplished. While dogs and other 
animals can provide great comfort and companionship, and we do not 
disagree with Veterans' subjective accounts that service dogs have 
improved the quality of their lives. At this time, there is not 
sufficient evidence that animals are effective in the treatment of 
mental health conditions, including Post Traumatic Stress Disorder 
(PTSD). Consequently, VA does not provide service dog benefits for 
mental health service dogs. VA is currently evaluating the efficacy of 
mental health service dogs pursuant to a congressionally mandated study 
to learn whether service dogs and/or emotional support dogs can be 
effective in treating or rehabilitating persons with PTSD. The study, 
expected to take several years to complete, is currently ongoing at 
three sites (Atlanta, GA; Iowa City, IA; and Portland, OR) and has 
begun pairing enrolled Veterans with dogs.

    Question 15.  The following is from a veteran in Kenai: ``I'm on 
ten different types of medications that deal with sleep, back pain, 
depression, anxiety, blood pressure, and inflammation * * *. I've 
really lost count of what I'm taking. I'm sick of it. I don't want to 
take any more medications. I would like to see if we can make a push 
for the VA to fund holistic style medical treatments. I believe in 
these, and I believe that they are cheaper rather than pushing big 
pharma on us. I for one am sick of it and would rather live in a state 
of depression and anxiety as opposed to taking 10+ pills a day. I'm 
also battling with the VA for an increase in VET benefits. They have 
turned down request for shoulder pain connected disability; they've 
turned down requests for increase in ringing in my ears but will give 
me pills!''
    I am glad the VA and the Committee is addressing this, it is very 
real, and how would you respond to this veteran?
    Response. Thank you for raising this important point. The problems 
you mention affect our entire nation and this is an issue we are 
challenged to manage effectively for our Veterans as well. The VA is 
actively addressing these problems in multiple ways, as well as 
contributing to the national effort, outlined in the National Pain 
Strategy, to improve the education and training of all health 
professionals, including those who eventually will care for our 
Veterans and military. The potential for side effects and toxicity 
increases when medications that affect the central nervous system (the 
brain and spinal cord) are prescribed together for symptoms of 
different, but sometimes related, conditions such as sleep disorders, 
chronic pain conditions, anxiety and depression disorders, Traumatic 
Brain Injury (TBI) and PTSD. To help combat this problem the VA can 
take advantage of its unique combination of assets, such as its 
electronic medical record and its Veterans Health Administration (VHA)-
wide communication and education systems which reach all facilities and 
providers.
    VHA has developed a new tool, the Opioid Therapy Risk Report 
(OTTR), which is available now to all VHA Primary Care clinicians when 
treating a Veteran with opioid therapy for chronic pain. This report 
provides information about the dosages of opioid analgesics and other 
centrally active medications such as benzodiazepines, significant 
medical and psychiatric problems that could contribute to an adverse 
drug reaction, and monitoring data to aid in the review and management 
of complex patients. OTTR is right on the dashboard of the electronic 
medical record, which enables VA providers to review this pertinent 
clinical data related to pain treatment all in one place while actually 
talking to patients about their symptoms and medications. As a result, 
Veterans are afforded a comprehensive Veteran-centered and more 
efficient level of pain management not previously available to Primary 
Care providers. VHA is actively deploying training aids to providers 
and facilities to familiarize them with how to utilize this tool in 
their daily practice.
    VHA has formalized several education and academic detailing 
projects that provide all VA prescribers and facilities guidance and 
education on safe symptom management. One program is the OSI, which 
monitors reductions in potential risks such as prescribing opioids and 
benzodiazepines together or high doses of opioids, monitors how 
facilities are increasing the use of evidence-based alternative 
treatments such as cognitive behavioral therapies and integrative 
medicine (CAM) (which are now required to be available in all 
facilities as alternatives to medication), and also provides feedback 
and support for providers whose prescribing profiles do not meet 
acceptable clinical standards. An OSI Toolkit with detailed education 
and guidance for both providers and patients is available on the VA's 
Pain Management Intranet and Internet sites and has been widely 
presented throughout the VHA in multiple educational formats and 
communications. For example, the Toolkit has detailed instructions 
about guiding safe medication tapers when clinically indicated.
    Programs such as the ATACS are presently training physicians in 
medical acupuncture and providers in ``battlefield (auricular) 
acupuncture'' across both systems. Already 1,293 Providers have been 
trained in battlefield acupuncture in military treatment facilities VA 
hospitals across the country.
                                 ______
                                 
Response to Posthearing Questions Submitted by Hon. Richard Blumenthal 
 to Robert A. Petzel, MD, Under Secretary for Health, Veterans Health 
       Administration (VHA), U.S. Department of Veterans Affairs
    Question 16.  I have heard from one of my constituents that it is 
difficult for some veterans to obtain their VA Identification Card, 
which is required to obtain VA health benefits. Can you please provide 
information about the process a veteran needs to follow and what are 
the criteria to obtain these benefits?
    Response. The Veterans Health Identification Card (VHIC) is for 
identification and check-in at VA appointments. It cannot be used as a 
credit card or an insurance card, and it does not authorize or pay for 
care at non-VA facilities. To receive a VHIC, a Veteran must be 
enrolled. If the Veteran is not enrolled, the Veteran may apply for 
enrollment online at www.va.gov/healthbenefits/enroll, by calling 1-
877-222-VETS (8387), or apply for enrollment in person at his or her 
local VA medical facility.
    In February 2014, VA began issuing the VHIC to newly enrolled 
Veterans and enrolled Veterans who were not previously issued the old 
VIC but requested an identification card. Enrolled Veterans who were 
not issued the old VIC may contact their local VA medical center 
Enrollment Coordinator to arrange to have their picture taken for the 
new VHIC, or they may request a new VHIC at their next VA health care 
appointment.
    Veterans who are already enrolled should ensure the address VA has 
on file is correct so you can receive your VHIC in a timely manner. For 
more information, please visit http://www.va.gov/HEALTHBENEFITS/vhic/
index.asp.

    Chairman Sanders. Dr. Petzel, thank you very much.
    General Coots.

 STATEMENT OF BRIGADIER GENERAL NORVELL V. COOTS, USA, DEPUTY 
  COMMANDING GENERAL (SUPPORT), U.S. ARMY MEDICAL COMMAND AND 
 ASSISTANT SURGEON GENERAL FOR FORCE PROJECTION, OFFICE OF THE 
  SURGEON GENERAL, U.S. ARMY; ACCOMPANIED BY COLONEL KEVIN T. 
    GALLOWAY, USA, DIRECTOR, ARMY PAIN MANAGEMENT PROGRAM, 
           REHABILITATION AND REINTEGRATION DIVISION

    General Coots. Chairman Sanders, Ranking Member Burr, and 
distinguished Members of this Committee, thank you for the 
opportunity to appear before you to discuss some of the Army 
Medicine's initiatives to address health and pain management 
needs of our servicemembers. I am accompanied by Colonel 
Galloway, who is the director for Army Medicine's Pain 
Management Program.
    On behalf of the over 150,000 dedicated soldiers and 
civilians that make up Army medicine, I want to extend our 
appreciation to Congress for the support given to military 
medicine which provides the resources we need to deliver 
leading-edge health services to our warriors, families, and 
retirees.
    The Army has been engaged over the last 13 years in combat 
operations and related activities that have challenged the 
bodies and spirits of our soldiers and their families. Army 
medicine has worked with our sister services and the Veterans' 
Health Administration to meet the emerging medical needs of our 
servicemembers and veterans.
    Our initiatives which are detailed further in my written 
testimony are aimed at improving outcomes, increasing safety, 
and enhancing the transition of care to the VA.
    Treating pain is one of medicines oldest and more 
fundamental responsibilities. Yet modern medicine continues to 
struggle in its efforts to understand pain mechanisms and to 
relieve pain and suffering of our patients. These complex 
issues impact patients, providers, leaders, and organizations 
across the military, the VA, and in the civilian sector. 
Effective solutions must involve innovative strategies, 
comprehensive solutions, and collaborative efforts.
    While the complicated nature of pain management and 
overmedication is not unique to the military or military 
medicine, we do face some unique challenges. We provide medical 
care on the battlefield and across an 8,000-mile medical 
evacuation chain that moves injured servicemembers from remote 
locations to U.S. hospitals with lightening efficiency.
    I have been there receiving our wounded warriors during my 
time in Afghanistan as well as at Walter Reed when I was the 
hospital commander. I know that for military medical providers, 
we begin pain management on the battlefield at the point of 
injury and continue throughout evacuation, treatment, and 
recovery.
    Army medicine initiative aimed at non-opioid medications 
and regional nerve blocks to provide local relief are important 
to expanding opioid sparing strategies at the earliest moments 
of care.
    In 2010, the Army-led pain management task force was 
chartered to develop a comprehensive, holistic, and multi-
disciplinary pain management strategy for the DOD. The Army has 
been working to implement the task force recommendations 
through the Army pain management campaign and while continuing 
to build collaborations both inside and outside of the 
Department of Defense.
    Current Army initiatives are aimed at improving pain 
management, patient care and safety, and reducing adverse 
outcomes related to prescription drugs. These are all a part of 
comprehensive strategy that includes establishing a network of 
standardized pain management capabilities, developing the DOD 
pain assessment screening tool, and outcomes registry by 
leveraging previous NIH investment in research, comprehensive 
medication reviews, and pharmacy screening tools within the 
medical home which is our primary care model to identify active 
duty servicemembers at increased risk, expanding the role of 
clinical pharmacists by embedding them in the medical home as a 
member of the comprehensive care team, improving pain 
management specialty support to primary care providers through-
out pain ECHO tele-mentoring initiative, expanding our 
understanding and utilization of effective integrative medicine 
modalities such as acupuncture, yoga, medical massage, and 
biofeedback through our collaborative partnerships and 
collaboration with the National Center for Complementary and 
Alternative Medicine and the Defense and Veterans' Center for 
Integrative Pain Management on research studies of non-
medication complements or alternatives to standard pain 
management therapies.
    There efforts have been associated with fewer adverse drug-
related events, reduced hospital admissions, improved patient 
outcomes, and overall cost avoidance.
    Finally, I would like to mention ongoing work with the VA 
to endure the smooth transition of care as servicemembers enter 
the VA system. The overarching pain management task force 
objective is to provide a standardized DOD and VA approach to 
optimize the care for warriors and their families.
    Our providers and patients benefit from a standardized 
approach to pain management while they are in uniform and as 
they transition to the VA health care system.
    I want to thank my partners in the DOD, the VA, and our 
colleagues testifying here today for the efforts made and our 
shared goals.
    I also want to thank Congress and the Committee for your 
continued support and I look forward to your questions. Army 
medicine is serving to heal and honored to serve.
    [The prepared statement of General Coots follows:]
   Prepared Statement of Brigadier General Norvell V. Coots, Deputy 
 Commanding General (Support), U.S. Army Medical Command and Assistant 
 Surgeon General for Force Projection, Office of the Surgeon General, 
United States Army and Colonel Kevin T. Galloway, Army Pain Management 
Program Director, Rehabilitation and Reintegration Division, Office of 
                the Surgeon General, United States Army
    Chairman Sanders, Ranking Member Burr, and Distinguished Members of 
this Committee--thank you for the opportunity to appear before you to 
discuss some of the Army Medicine's initiatives to address healthcare 
needs of our Soldiers, specifically as they relate to the challenges 
the entire Nation is facing with pain management and the use of 
opioids. On behalf of the over 150,000 dedicated Soldiers and civilians 
that make up Army Medicine, I want to extend our appreciation to 
Congress for the support given to military medicine, which provides the 
resources we need to deliver leading edge health services to our 
Warriors, Families and Retirees. I'm accompanied today by Colonel Kevin 
Galloway, Director for Army Medicine's Pain Management Program.
    The Army has been engaged over the last 13 years in combat 
operations and related activities that have challenged the bodies and 
spirits of our Soldiers and their families. Throughout this intensive 
period of military operations, Army Medicine, along with our Sister 
Services and the Veterans Health Administration (VHA), have been 
evolving and adapting to meet the emerging medical needs of our 
wounded, ill, and injured Servicemembers and Veterans. While some of 
the medical challenges facing Servicemembers and Veterans are unique to 
the military and military medicine, the challenges related to pain 
management and the potential overuse, abuse, and diversion of pain 
medications are shared by the Nation at large. These complex issues 
impact patients, providers, leaders and organizations across the 
military health system, the VHA, and civilian medicine. Consequently, 
effective solutions and strategies will involve patients, providers, 
leaders and organizations across military, VHA and civilian medicine. I 
would like to share some of our innovative strategies, comprehensive 
solutions, and collaborative efforts with you today as well as 
emphasize our commitment to continuous improvement and research 
efforts.
                            pain management
    First, I'd like to place the challenges of pain management in some 
context. Treating pain is one of medicine's oldest and most fundamental 
responsibilities, yet modern medicine continues to struggle in its 
efforts to understand pain mechanisms and to relieve pain and suffering 
for our patients. Pain is an enigmatic issue for medicine that places 
significant burdens on patients, families, medical providers, and 
employers. Pain is the most frequent reason patients seek medical care 
in the United States. A 2011 Institute of Medicine (IOM) Report noted 
that more than 116 million Americans suffer from chronic pain. The 
annual cost of chronic pain in the U.S. is estimated at $560 billion, 
including health care expenses, lost income, and lost productivity. The 
Centers for Disease Control identified prescription medication abuse as 
an ``epidemic'' in the United States. The military is not immune to 
these challenges.
    In 2010, the Army-led Pain Management Task Force was chartered to 
develop a comprehensive, holistic, multidisciplinary, and multimodal 
strategy utilizing state-of-the-art/science practices in the field. 
Comprised of representatives from the Uniformed Services and VHA, the 
Pain Management Task Force examined staff education, clinical practice, 
and the structure of pain management in military medicine, the VHA, and 
in civilian medicine. I would like to emphasize that the Task Force 
benefited immensely during this analysis from the VHA's previous and 
ongoing initiatives to develop and implement pain management 
strategies.
    The 2010 Pain Management Task Force Report has been widely 
circulated and recognized across U.S. Medicine and abroad. The American 
Academy of Pain Medicine recognized the Pain Management Task Force with 
its Presidential Commendation. One year after the release of the 
report, the IOM released its own report entitled, ``Relieving Pain in 
America,'' which acknowledged and referenced the work of the Pain 
Management Task Force. More importantly, the IOM report's findings and 
recommendations largely paralleled those contained in the Pain 
Management Task Force Report. When the IOM report was released in 
June 2011, the Army was already operationalizing the Pain Management 
Task Force's recommendations through the Comprehensive Pain Management 
Campaign Plan. Since the release of the IOM report, the Army has been 
representing the Department of Defense on the National Institutes of 
Health (NIH) Interagency Pain Research Coordinating Committee, the 
Federal advisory committee created by the Department of Health and 
Human Services to enhance pain research efforts and promote 
collaboration across the government.
    The Comprehensive Pain Management Campaign Plan provides a roadmap 
for this holistic, multimodal, multidisciplinary pain management 
strategy. Army Medicine's pain strategy includes several lines of 
effort: first, to implement a culture of pain awareness, education, and 
proactive intervention; second, to provide tools and infrastructure 
that support and encourage practice and research advancements in pain 
management; and last, to build a full spectrum of best practices for 
the continuum of acute and chronic pain, based on a foundation of the 
best available medical evidence.
    The foundation of the MEDCOM pain management program is developing 
a tiered or ``Stepped Care'' strategy that provides the appropriate 
level of pain management capability, provider education and access to 
consultative/referral support at each level of care (i.e. from Primary 
Care to Specialty Care). Interdisciplinary Pain Management Centers 
(IPMC) are being established at each of the Army's eight medical 
centers. IPMCs provide the highest tier of pain management delivered by 
a multidisciplinary team of providers working together to provide 
consultation, care, and expertise for interventional pain medicine. Our 
goals are rehabilitation and functional restoration through these 
integrative medicine modalities.
    The Army Pain Management Extension for Community Healthcare 
Outcomes (ECHO) tele-mentoring initiative leverages the model developed 
by the University of New Mexico (UNM) Project ECHO initiative. The Army 
is completing a two-year collaboration with UNM to adapt this best 
practice for use in the Army's pain program. ECHO's objective is to 
complement the capacity, competence and confidence of remote primary 
care providers. Utilizing weekly video teleconferencing to create 
regional communities of practice, ECHO links the IPMC specialty teams 
(i.e. hubs) with their designated Patient Centered Medical Homes (i.e. 
spokes). This improves provider knowledge, increases care coordination, 
and decreases the need for continued specialty referrals to the direct 
and purchased care systems.
             complementary integrative medicine modalities
    As recommended by the Pain Management Task Force, the integrative 
medicine modalities in our IPMCs include acupuncture, movement therapy/
yoga, medical massage, and bio-feedback. The use of these modalities in 
our IPMCs provides our patients with non-medication pain management 
options. The Army has been collaborating with several organizations 
with a common interest in expanding the utilization of complementary 
integrative medicine modalities. The National Center for Complementary 
and Alternative Medicine at NIH, the Bravewell Collaborative, and the 
Samueli Institute have all been extremely helpful in this effort.
    Army clinicians are participating with the Air Force, Navy, and VHA 
in a $5.4 million Joint Incentive Fund Project to field a standardized 
basic acupuncture training and sustainment model across DOD and VHA 
medical facilities. Training teams have already started traveling to 
Army, Navy, Air Force, and VHA medical facilities to deliver this 
training. The response from providers and patients has been 
overwhelmingly positive.
    Army Medicine, along with the Navy and Air Force, is collaborating 
through the Defense and Vet Center for Integrative Pain Management on 
research studies related to the use of acupuncture and yoga as non-
medication complements/alternatives to standard pain management 
therapies. Initial evidence indicates these can be effective 
complements and sometimes an alternative to medications.
                       pain outcomes measurement
    In response to the 2010 National Defense Authorization Act and the 
recommendations in the Pain Management Task Force Report, the DOD began 
development of the Pain Assessment Screening Tool and Outcomes Registry 
(PASTOR). PASTOR was designed as a tool to reduce the burden of 
questionnaires during clinical contact through modern information 
technology, make use of well-established pain assessment tools already 
available, and provide a framework for development of new assessment 
tools. Furthermore, PASTOR is envisioned as a critical first step in 
realizing the vision of outcomes driven pain care across the DOD and 
VHA health care systems.
    The PASTOR prototype results in a clinician report, displaying 
alerts for concerning responses to questions covering PTSD, depression, 
anxiety, and alcohol use. These alerts are intended to prompt further 
individualized evaluation by the clinician. Areas of greatest pain are 
mapped on an image of a body, and self-reported pain values are tracked 
over time. When these scores are analyzed in concert with validated 
measures of emotional (anxiety, depression, anger) and physical (sleep, 
physical function) health domains, trends are easily identified. 
Additionally, each patient has an opportunity to list and rate ability 
on activities that are important to that individual. This functional 
data provides practical indicators of pain management success. A new 
set of opioid use measures are also under development and will be field 
tested in both civilian and military setting later this year.
    A significant advantage in the PASTOR development program is its 
collaborative partnership and development strategy with the NIH Patient 
Reported Outcomes Measurement Information Systems, or PROMIS. PROMIS 
represents an existing Federal investment of approximately $100 
million, over 8 years of research and development, and the product of 
150 scientists at 15 primary research sites. PROMIS created more than 
80 royalty free instruments which can be used to capture numerous 
components of health related quality of life including physical health, 
mental health and social health. Computerized adaptive testing (CAT)--
enables computer-based delivery of measures which can obtain clinical 
accuracy in five items or less. Scientists at Northwestern University 
have teamed with the military to integrate brief PROMIS measures with 
the needs of military personnel and their families who require pain 
management. This reduction in patient burden, without loss of clinical 
reliability, enables PASTOR to frequently assess multiple facets of 
pain and opioid use.
    Thus far, a working prototype has been constructed, pain threshold 
values for appropriate initiation of PASTOR have been identified, and a 
pilot test of the system has begun in two military treatment 
facilities, with more to follow in the coming months.
    Army Medicine is adopting the Defense and Veterans Pain Rating 
Scale (DVPRS). Something as simple as changing how we ask our patients 
about their pain can impact the prevalence of medication use. The scale 
was developed by the Pain Management Task Force and validated through 
DOD/VHA research studies. It recalibrates the pain discussion along the 
lines of: ``How is pain affecting your function and quality of life?'' 
The scale includes supplemental questions on pain's effect on sleep, 
mood, stress and activity. The Army is integrating DVPRS into the 
Patient Centered Medical Home workflows.
                   pain management transition to vha
    Another area I'd like to highlight with regard to pain management 
is our ongoing collaboration with the VHA to ensure the smooth 
transition of care for Soldiers who will be receiving care in the VHA 
health system. Prominently positioned on the Pain Management Task Force 
Report cover is the overarching Task Force objective: ``Providing a 
standardized DOD and VHA vision and approach to pain management to 
optimize the care for Warriors and their Families.'' Army Medicine has 
continued to engage with the Air Force, Navy and VHA to move our 
organizations in that direction. The Army Pain Management Program's 
incorporation of the VHA's Stepped Care approach synchronizes provider 
education with the expectations of our patients. Not only do our 
military providers and patients benefit from a standardized approach to 
pain management while they are in uniform, but this also makes the 
transition to VHA care far less disruptive.
    DOD and VHA collaboration has also resulted in standardized 
prescription medication formularies to ensure Soldiers with chronic 
pain are able to continue effective care plans after their transition 
to the VHA. Last, military and VHA providers are engaged in a project 
to develop and implement a common pain management education curriculum 
for both providers and patients. The curriculum will be fully developed 
within the next twelve months, and will be implemented across VHA and 
DOD within the next eighteen months. These initiatives will take us 
closer to the standardized DOD and VHA vision and approach to pain 
management referenced by the Pain Task Force.
    In addition to the Pain Management Campaign, Army Medicine is 
addressing the potential overuse, abuse and diversion of opioids 
through a comprehensive strategy that integrates several other 
initiatives including Polypharmacy, Substance Abuse, Behavioral Health, 
and Warrior Transition Care.
                              polypharmacy
    Soldiers with complex injuries often require the use of multiple 
medications (i.e. polypharmacy) which can place them at greater risk 
for medication-related adverse events. The Army seeks to reduce risk, 
enhance safety and optimize care by including the Soldier, Family 
members, healthcare providers, pharmacists and commanders as part of 
the healthcare team. Army policies also establish procedures to 
identify polypharmacy trends that could lead to misuse by Soldiers and 
Wounded Warriors.
    Army Medicine uses best practices that are comparable to, or 
exceed, civilian programs, such as prescription drug monitoring to 
identify polypharmacy cases. Positive interventions include 
comprehensive medication reviews, sole provider programs, limiting the 
dispensed supply of medication, restricting high-risk patients to the 
utilization of one pharmacy, informed consent, use of non-drug 
treatment options, clinical pharmacist referrals, and patient and 
provider education.
    The Army trains its providers on the risks of prescription opioid 
overuse and ways to prevent medication misuse. The US Army Public 
Health Command and the Uniformed Services University of the Health 
Sciences developed an interactive storyline-based training aimed at 
increasing the knowledge and skills health professionals need to better 
interact with Soldiers in a clinic setting. Army Medicine has 
implemented systems and procedures our clinicians regularly use to 
prevent and detect issues of opioid overuse. These tools include the 
ability for our clinicians to review all prescriptions paid for by the 
Defense Health Agency (DHA) pharmacy benefit regardless of the point of 
service (Military, Home Delivery or Retail Pharmacy). The DHA 
Pharmacoeconomic Branch Web site allows clinicians to identify 
concerning use of opioids dispensed under the TRICARE Pharmacy Benefit 
through the use of prescription screening tools such as the Medication 
Analysis and Reporting Tools.
    Army Medicine is expanding the role of clinical pharmacists to 
address national concerns with polypharmacy and adverse drug events 
that lead to hospital admissions. The Army Surgeon General supports 
evidence-based enhancements drawing on the expertise and contributions 
of pharmacists embedded in Patient-Centered Medical Homes. The addition 
of clinical pharmacists to the patient care team translates into 
decreased overall costs, fewer adverse drug-related events, reduced 
hospital admissions, and improved medication-related patient outcomes 
and appropriate adherence to medications. Clinical pharmacists improve 
readiness of the force through policy and practice, systematically 
identifying Soldiers with polypharmacy risk and communicating these 
concerns to health care providers. The Army uses an automated 
polypharmacy screening tool to screen all Active Duty Servicemembers 
monthly to identify Soldiers prescribed different combinations of high 
risk medications. These reports are provided to the medical team for 
review and follow-up. Clinical pharmacists embedded in Army medical 
homes optimize patient adherence to appropriate drug therapy by 
conducting medication reviews, resolving medication problems and 
recommending cost effective treatment alternatives.
    Current Army initiatives aimed at reducing adverse outcomes and 
harm due to prescription drug abuses include informed consent for 
polypharmacy, sole provider program, limiting authorized use of 
prescriptions to six months following the prescription fill date, 
adjusting the panel of drugs in random urine drug testing to include 
prescription drugs and polypharmacy education for healthcare providers 
and patients.
    Healthcare providers must review identified risks and potential 
interactions with the Soldier, provide education on detection and 
management of interactions, and must document informed consent in the 
medical record. Informed consent includes a brief description of 
discussed risks and whether or not the indication for which the 
medication is being used is a Food and Drug Administration (FDA) 
approved indication or the medication is used off-label.
    The Army policy instructs healthcare providers to have a low 
threshold for referring patients to Behavioral Health resources and the 
Sole Prescriber Program. Healthcare providers enroll Soldiers at 
increased risk of adverse effects, drug interactions, or inappropriate 
medication use in the Sole Prescriber Program to optimize care. Once 
enrolled, only a Soldier's designated provider or alternate provider is 
authorized to prescribe controlled substances for the Soldier. If 
necessary, the Soldier may be restricted to a specific pharmacy or 
pharmacies by activating the Prescription Lock-out Program.
    In addition to Soldiers who are identified as having intentional or 
unintentional risk for medication overdose, healthcare providers will 
refer Soldiers who present with polypharmacy-related concerns to a 
clinical pharmacist. The pharmacist will identify medication-related 
problems, develop a medication action plan, and provide medication 
education to the patient. Clinical pharmacists document patient 
encounters and consultations for medication therapy management in an 
electronic medical record template to improve communication with 
providers.
    Army policy limits authorized use of prescriptions to six months 
following the prescription fill date. In addition, Army medical 
providers may prescribe only the minimum quantity of controlled 
substances necessary to treat an acute illness or injury, and 
quantities of controlled substances used to treat acute conditions are 
dispensed as a 30-day supply. Prescribers and pharmacists inform 
Soldiers that, per Army policy, controlled substance prescriptions have 
an expiration date of six months from the dispensed date, and that a 
positive urinalysis test for the drug after six months from dispensing 
may result in a ``no legitimate use'' finding.
    Polypharmacy education and training is available to healthcare 
providers and beneficiaries to improve appropriate prescribing and use 
of medications, respectively. Patient-specific training is available to 
Warrior Transition Units (WTU) to improve awareness of safe medication 
use, proper medication disposal, and promotion for the bi-annual drug 
take back events.
    Army Medicine has participated in all Drug Enforcement Agency (DEA) 
National Prescription Drug Take Back Day events since their inception 
in 2010. Thirty-six Army Military Treatment Facilities participated in 
the Take Back Day on 25 and 26 October 2013, with over 2,000 patients 
participating and 7,491 pounds of unused medications collected. The 
Army will continue to participate in bi-annual Take Back events in an 
effort to maintain attention on the importance of appropriate disposal 
of medications that are no longer needed. Army Medicine provides 
support through coordinated public affairs communications and education 
directed at medical staff, patients, Families and military leadership, 
to include on-site presence at every designated event.
                        substance abuse programs
    The Army continues to synchronize clinical care and processes 
provided through the Army Substance Abuse Program and Army Medical 
Command's primary care providers, pain specialists, and behavioral 
health specialists. The Army uses the DOD's drug testing program to 
test not only for illegal drugs, but also for prescribed medications 
taken inappropriately (that is without an active prescription). 
Identified Soldiers are referred to the Army Substance Abuse Program 
where they are assessed and enrolled for treatment. Commanders and 
clinicians support this treatment process regardless of the Soldier's 
disposition, because we recognize that we have an obligation to ensure 
our Soldiers remain effective on active duty or make their transition 
from active service with drug use properly managed.
                       behavioral health program
    Army Medicine's Behavioral Health Service Line is an interconnected 
group of standardized programs delivering a wide variety of Behavioral 
Health services to Soldiers and beneficiaries. For the treatment of 
substance abuse disorders, the Army has five Addiction Medicine 
Intensive Outpatient Programs. There are currently 187 beds designated 
for long-term Substance Use Disorder treatment in the Military Health 
System, 22 of which are in the Army. These Military Health System 
facilities have consistently had 85% or higher utilization rates for 
the past 18 months. Purchased care inpatient substance use disorder 
treatment accounts for approximately 70 Soldiers per month. Demand for 
network inpatient substance use disorder treatment has decreased 
sharply with the implementation of the NDAA 2010, Section 596, but 
continues to remain high enough to justify increases in capacity in the 
coming years to recapture inpatient substance use disorder care going 
to the network.
    Army Medical Command conducted an analysis of all health care and 
pharmacy records involving Army Active Duty Servicemembers, reflecting 
an annual average population of 657,000 Soldiers from 2007 to 2012. 
This analysis showed a 65% increase in the number of Soldiers seeking 
behavioral health services (151,620 in 2007 to 250,410 in 2012), and a 
corresponding 44% increase in the number of Soldiers prescribed any 
medication within the broad psychiatric category (101,914 in 2007 to 
147,197 in 2012). In other words, there has not been any 
disproportionate increase in medication use. There are multiple 
safeguards in place to ensure that psychiatric medications, including 
antipsychotic medications, are prescribed safely and judiciously 
according to accepted clinical practice guidelines and nationally 
recognized standards of care.
              medical home and warrior transition clinics
    Optimizing the use of medications through pharmacist interaction as 
part of a Patient Centered Care Team is best exemplified by their work 
within the Wounded Warrior Clinics. Of the 22 Warrior Clinics in 
support of Army Medicine Warrior Transition Units, 21 Clinics are 
currently supported by approximately 25 clinical pharmacists and 5 
pharmacy technicians. These Warrior Clinics are consistent with the 
Medical Home model, where pharmacists manage complex medication 
regimens and mitigate risks for Wounded Warriors.
    The Risk Assessment Management within the Warrior Care and 
Transition Program enables WTUs to monitor the safety of Soldiers. WTU 
Commanders, in coordination with the Soldiers' interdisciplinary team, 
conduct risk assessments for every Soldier. The initial risk assessment 
occurs within 24 hours of the Soldier's arrival at the WTU, ongoing 
assessments are regularly made throughout the Soldier's stay, and 
additional assessments occur during key events such as during quarterly 
scrimmages as directed by the Soldier's personalized Comprehensive 
Training Plan. Risk assessments focus on therapy adherence, behavioral 
health history, substance abuse history, and access to care patterns. 
The intent is to assess whether Soldiers on these medications need 
additional monitoring and assistance with medication management. If a 
Soldier is identified as needing additional monitoring and assistance, 
the interdisciplinary team determines what risk mitigation strategies 
are needed to maintain the Soldier's safety. If needed, the Soldier is 
entered into the Army Medical Department's Sole Provider Program. 
Soldiers enrolled in the Sole Provider Program may only receive 
medications from their assigned provider, and receive no more than a 7-
day supply of narcotics or psychotropic medications. Clinical 
Pharmacists also provide oversight as they review the medication 
profiles of all Soldiers in a WTU, who are determined to be at high 
risk. These reviews occur at least weekly.
    Army Medicine has engaged in a comprehensive campaign to address 
the pain management needs of Soldiers and their Families. Our strategy 
involves developing and implementing solutions with our DOD, VHA, and 
Civilian Medicine partners. Thank you again for the opportunity to 
testify before the Committee and for your support to our Soldiers and 
Veterans.
                                 ______
                                 
Response to Posthearing Questions Submitted by Hon. Bernard Sanders to 
  BG Norvell V. Coots, USA, Deputy Commanding General (Support), U.S. 
     Army Medical Command and Assistant Surgeon General for Force 
          Projection, Office of the Surgeon General, U.S. Army
              complementary and alternative medicine (cam)
    Question 1. How can the Army improve access to CAM therapies among 
servicemembers? How can it help improve what information is available 
to servicemembers and their providers about CAM services?
    Response. In Army Medicine, perhaps the single greatest application 
of Complementary and Alternative Medicine (CAM) has been seen in pain 
management. Initially, Servicemembers were often the ones who 
identified integrative medicine treatments to their medical providers 
as uniquely effective in restoring and maintaining their health with 
minimal side effects. In response to this call to action and as a 
result of increasing medical evidence, Army Medicine has deliberately 
expanded its experience and utilization with integrative medicine as 
part of the Army's Comprehensive Pain Management Program.
    The Army Pain Program has been moving toward a more multi-
disciplinary, multi-modal pain management strategy that leverages 
selected CAM modalities alongside more conventional pain management 
treatments such as medications and interventional procedures such as 
injections, nerve blocks, and surgeries. In addition to chiropractic 
care, the Army's Interdisciplinary Pain Management Centers are 
employing modalities such as acupuncture, massage therapy, movement 
therapies to include yoga, and biofeedback. These are all proving to be 
effective complements and sometimes alternatives to medications.
    Army Medicine will continue to expand the utilization and 
collection of evidence regarding the efficacy of integrative medicine 
modalities alongside more conventional therapies.

    Question 2. What factors currently limit DOD from further 
broadening CAM therapies across the Army and other branches?
    Response. Of the many treatment strategies addressed in the Army's 
Comprehensive Pain Management Campaign Plan, the use of CAM therapies 
has been one of the most challenging. As noted in the Army's 2010 Pain 
Task Force Report, there are an increasing number of reports in medical 
literature regarding the safety and efficacy of these treatment 
modalities, and their use is becoming more widespread across medicine. 
It is believed that the use of the various CAM modalities can lead to 
an improved sense of being, health status or functional outcome through 
pain reduction, lower medication usage or increased quality of life. 
However, there is still a paucity of evidence-based scientific 
literature on the precise role for these modalities in the overall 
management of acute and chronic pain.
    Per the Code of Federal Regulations, Section 199.4(g)(15), TRICARE 
is unable to pay for healthcare in the purchased care sector that has 
not been proven to be both safe and effective in the treatment of the 
underlying condition. While there have been an increasing number of 
articles published on the use of CAM for the treatment of acute and 
chronic pain, there have been no evidence-based clinical practice 
guidelines published or other evidence based protocols developed that 
incorporate the general use of CAM, or specific types of CAM.
    However, within the DOD, Military Treatment Facilities (MTFs) are 
allowed, under very specific conditions and specifications, to offer 
certain types of services that would otherwise not be covered benefits 
under TRICARE. That is the case with certain CAM therapies. Under these 
circumstances, the MTF Commander is responsible for ensuring that all 
existing community standards of care are met, to include any 
credentialing requirements of practitioners if they are not otherwise 
considered to be TRICARE authorized providers. Army Medicine is working 
with the Navy and Air Force to develop credentialing guidelines and 
oversight provisions to provide appropriate, standardized credentialing 
of practitioners who will employ CAM at our MTFs.
    One notable exception can be seen in the military's expanded use of 
chiropractic care. Unlike the other CAM modalities, chiropractic care 
was originally offered in 1995 as a demonstration program and later 
expanded as directed under Section 702 of the National Defense 
Authorization Act (NDAA) for Fiscal Year 2001. Three subsequent NDAA's 
allowed for expansion of the program, resulting in chiropractic 
services now being offered at 62 MTFs but still limited to Active Duty 
Servicemembers.
                          acupuncture training
    Question 3. How would the Joint Incentive Fund Project to implement 
a standardized acupuncture training and sustainment model across DOD 
and VA medical facilities improve acupuncture services the Army 
provides servicemembers? When can we expect system-wide implementation 
of this joint model?
    Response. The variances in acupuncture integration, utilization, 
reimbursement, and practice in health systems are not limited to 
Federal/military medicine. The absence of universally accepted 
protocols, credentialing, and clinical practice guidelines have 
inhibited more aggressive implementation across the DOD and VHA health 
systems. The $5.4 million, Joint Incentive Fund (JIF) acupuncture 
project will develop, pilot, evaluate and implement a uniform tiered 
acupuncture education and training program for Military Health System 
(MHS) and Veterans Health Administration (VHA) providers in order to 
provide initial and expanded access to this modality across MHS and VHA 
treatment facilities.
    The acupuncture JIF provides a pathway to uniform implementation 
and integration of this modality across military and VA healthcare 
systems through a proven practical program of training and 
certification for providers. It drives adoption and further development 
of acupuncture best practices across the MHS and VHA. The two-year 
acupuncture JIF project is scheduled to be completed by 2016. In 
progress reviews are provided to the Health Executive Council on a 
quarterly basis.

    Question 4. How many providers trained in acupuncture already 
working in the Army? How many of these providers exclusively offer 
acupuncture services? On average, how many hours per week do these 
offer acupuncture to servicemembers?
    Response. U.S. Army Medical Command (MEDCOM) providers, including 
physicians, physician assistants, nurse practitioners and dentists who 
wish to use acupuncture in their practice are required to document 
their acupuncture training and competency in their facility 
credentialing file. As of April 2014, 46 MEDCOM providers have added 
acupuncture to their credentialing files. None of these providers are 
exclusively offering acupuncture services but use acupuncture as a 
complementary modality in their practice.
    The number of hours per week where acupuncture is offered is not 
possible to calculate. However, the Army does capture the number of 
acupuncture procedure performance. In FY 2012, over 23,000 acupuncture 
procedures were performed in Army medical treatment facilities. The FY 
2013 numbers for acupuncture utilization is currently unavailable but 
should trend upwards.
    The Army pain management program has been working to integrate 
licensed acupuncturists in the eight Army interdisciplinary pain 
management clinics. These individuals are being hired with a primary 
responsibility to provide acupuncture. At this time, the Army Pain 
Program, along with the Air Force, Navy, and VHA are working to 
standardize coding, treatment protocols, and credentialing for licensed 
acupuncturists.

    Question 5. Is the current amount of acupuncture offered within the 
Army sufficient to meet the demand for this therapy? If not, what 
efforts are being made to ensure an adequate number are available to 
treat veterans once the joint model is implemented?
    Response. The current capacity within the Army direct healthcare 
system is insufficient to support the perceived demand for acupuncture.
    While the Joint Incentive Fund acupuncture project to field a 
standardized basic acupuncture training and sustainment model across 
DOD and VHA will greatly improve access to basic acupuncture 
techniques, there will likely be a need for additional organized 
efforts to increase the enterprise wide training, availability, and 
utilization of acupuncture and other complementary integrative 
modalities.
                          dod/va collaboration
    Question 6. What benefits has DOD seen from the standardization of 
the prescription medication between VA and DOD available to both 
servicemembers and veterans? Are servicemembers able to continue their 
existing course of treatment as they transition to VA health care?
    Response. Ongoing efforts to harmonize formularies are aimed at 
improving continuity of care for DOD beneficiaries transitioning to the 
VA. The VA has established policy that supports the continuation of DOD 
prescribed medications upon transfer whether or not the drug is listed 
on the formulary or if its use is consistent with VA prescribing 
guidelines. The VA provider is permitted to change previously 
prescribed medications to allow consistency with prescribing guidelines 
after careful consideration and implementation to prevent avoidable 
problems.

    Question 7. What other efforts have DOD and VA taken to collaborate 
and standardize treatment options available to servicemembers and 
veterans for chronic pain?
    Response. Phased implementation of the Comprehensive Pain 
Management Campaign Plan is ongoing across Army Medicine and Tri-
Service/VA implementation of Task Force recommendations continues as 
part of Health Executive Council Pain Management Work Group. In FY 
2013, Army, Air Force, Navy, and the VA demonstrated increased interest 
and activity in synchronized implementation of Pain Task Force 
Recommendations. Uniformed Services and the VA will focus on executing 
several joint pain management projects as listed below. These projects 
will provide information to Defense Health Agency and Uniformed 
Services in order to facilitate re-evaluation and possible revisions of 
policies.

    a. Pain Management Outcome Tool
    b. Tiered Acupuncture Course for Primary Care Providers
    c. Development/Implementation of DOD/VHA education curriculum
    d. Synchronized DOD/VA transition policies for medications

    One specific project that highlights DOD/VA collaboration is the 
basic acupuncture training course. Army clinicians are participating 
with the Air Force, Navy, and VHA in a $5.4M Joint Incentive Fund 
Project to field a standardized basic acupuncture training and 
sustainment model across DOD and VHA medical facilities. Training teams 
have already started traveling to Army, Navy, Air Force, and VHA 
medical facilities to deliver this training. The response from 
providers and patients has been overwhelmingly positive.
                                 ______
                                 
Response to Posthearing Questions Submitted by Hon. Richard Blumenthal 
to BG Norvell V. Coots, USA, Deputy Commanding General (Support), U.S. 
     Army Medical Command and Assistant Surgeon General for Force 
          Projection, Office of the Surgeon General, U.S. Army
    Question 8. Do you have any further breakdown as to the usage for 
each of the branches of the Armed Forces?
    Response. Yes. Information is available on the usage of opiates for 
all branches of the Armed Forces. Question #9 and #10 responses provide 
information for Army Servicemembers.

    Question 9. How much of the opioid use is for acute conditions and 
for chronic conditions?
    Response. For acute conditions, the proportion of Active Duty Army 
Servicemembers prescribed an opiate medication at least once in a year 
for the last 10 years is as follows:

                2004--21%
                2005--22%
                2006--25%
                2007--26%
                2008--26%
                2009--26%
                2010--27%
                2011--29%
                2012--29%
                2013--27%

    Chronic opioid use is defined as cumulative use of 90 or greater 
days of use in a six-month period. Information on chronic use is 
provided in the response to question #10.

    Question 10. How much opioid use is for >90 days in duration?
    Response. Chronic opioid use is defined as cumulative use of 90 or 
greater days of use in a six-month period. The proportion of Active 
Duty Army Servicemembers with any chronic opiate use in a year is as 
follows:

                2004--1.27%
                2005--1.54%
                2006--1.76%
                2007--1.96%
                2008--1.95%
                2009--1.97%
                2010--2.09%
                2011--2.36%
                2012--2.57%
                2013--2.34%
                                 ______
                                 
 Response to Posthearing Questions Submitted by Hon. Mark Begich to BG 
 Norvell V. Coots, USA, Deputy Commanding General (Support), U.S. Army 
  Medical Command and Assistant Surgeon General for Force Projection, 
                Office of the Surgeon General, U.S. Army
    Question 11. PTSD, depression, TBI, family stress, disability, and 
joblessness plague our veterans' community and increase the risk of our 
veterans overmedicating to soothe chronic pain. How are you addressing 
growing mental health issues in conjunction with pain management? How 
does this initiative take into account rural and remote locations that 
may not have Behavioral Health professionals or telehealth?
    Response. In the past several years, the Army has vastly expanded 
and completely overhauled its system of behavioral healthcare and pain 
management program to address complex co-morbidities and co-occurring 
conditions.. The Army's Behavioral Health Service Line is comprised of 
11 interconnected standardized programs that provide consistent and 
ready access to behavioral health services covering all behavioral 
health conditions across our supported beneficiary population.
    The 2010 Army-led Pain Management Task Force was chartered to 
develop a strategy that is comprehensive, holistic, multidisciplinary, 
and multimodal, utilizing state-of-the-art/science practices in the 
field resulting in the Comprehensive Pain Management Campaign Plan. 
Army Medicine's pain strategy includes three primary lines of effort: 
1) implement a culture of pain awareness, education, and proactive 
intervention, 2) provide tools and infrastructure that support and 
encourage practice and research advancements in pain management, and 3) 
build a full spectrum of best practices for the continuum of acute and 
chronic pain, based on a foundation of the best available medical 
evidence. This includes incorporating behavioral health care as part of 
pain management solutions and ensuring pain management for Soldiers and 
pain management training for providers outside of the main area of 
care.
    Soldiers with complex injuries often require polypharmacy, or the 
use of multiple medications, which place them at greater risk for 
medication-related adverse events. The Army seeks to reduce risk, 
enhance safety and optimize care by including the Soldier, Family 
members, healthcare providers, pharmacists and commanders as part of 
the healthcare team. Army policies establish procedures to identify 
polypharmacy trends that could lead to misuse by Soldiers and Wounded 
Warriors.
    Army Medicine also uses best practices that are comparable to, or 
exceed, civilian programs, such as prescription drug monitoring to 
identify polypharmacy cases. Positive interventions include 
comprehensive medication reviews, sole provider programs, limiting the 
dispensed supply of medication, restricting high-risk patients to the 
utilization of one pharmacy, informed consent, use of non-drug 
treatment options, clinical pharmacist referrals, and patient and 
provider education.
    The Army trains its providers on the risks of prescription opioid 
overuse and ways to prevent medication misuse. Army Medicine has 
implemented systems and procedures our clinicians regularly use to 
prevent and detect issues of opioid overuse. These tools include the 
ability for our clinicians to review all prescriptions paid for by the 
Defense Health Agency (DHA) pharmacy benefit regardless of the point of 
service (Military, Home Delivery or Retail Pharmacy).
    The Army policy instructs healthcare providers to have a low 
threshold for referring patients to Behavioral Health resources and the 
Sole Prescriber Program. Healthcare providers enroll Soldiers at 
increased risk of adverse effects, drug interactions, or inappropriate 
medication use in the Sole Prescriber Program to optimize care. Once 
enrolled, only a Soldier's designated provider or alternate provider is 
authorized to prescribe controlled substances for the Soldier. If 
necessary, the Soldier may be restricted to a specific pharmacy or 
pharmacies by activating the Prescription Lock-out Program.
    In addition to Soldiers who are identified as having intentional or 
unintentional risk for medication overdose, healthcare providers will 
refer Soldiers who present with polypharmacy-related concerns to a 
clinical pharmacist.
    Army Medicine is expanding the role of clinical pharmacists to 
address national concerns with polypharmacy and adverse drug events 
that lead to hospital admissions. The Army Surgeon General supports 
evidence-based enhancements drawing on the expertise and contributions 
of pharmacists embedded in Patient-Centered Medical Homes.
    Army Medicine has participated in all Drug Enforcement Agency (DEA) 
National Prescription Drug Take Back Day events since their inception 
in 2010. Thirty-six Army Military Treatment Facilities participated in 
the Take Back Day on 25 and 26 October 2013, with over 2,000 patients 
participating and 7,491 pounds of unused medications collected. The 
Army will continue to participate in bi-annual Take Back events in an 
effort to maintain attention on the importance of appropriate disposal 
of medications that are no longer needed. Army Medicine provides 
support through coordinated public affairs communications and education 
directed at medical staff, patients, Families and military leadership, 
to include on-site presence at every designated event.
    Specific to Telehealth, the Army has developed and vastly expanded 
a comprehensive Telehealth system over the past several years that now 
enables the Army to cross-level clinical care capacity across the 
globe. In fiscal year 2013, Army clinicians offered care across 18 time 
zones and in over 30 countries and territories, to include remote 
locations where Soldiers serve. In fiscal year 2013, Army clinicians 
provided over 34,000 patient encounters and provider-to-provider tele-
consultations in garrison; approximately 85 percent of these encounters 
were related to outreach via Tele-Behavioral Health.
    The Army's Pain Management Task Force recommended the Army ``Expand 
telemedicine capabilities to incorporate pain management initiatives'' 
(Pain Management Task Force, 2010). The Army Pain Management Extension 
for Community Healthcare Outcomes (ECHO) tele-mentoring initiative 
leverages the model developed by the University of New Mexico (UNM) 
Project ECHO initiative. The Army is completing a two-year 
collaboration with UNM to adapt this best practice for use in the 
Army's pain program. ECHO's objective is to complement the capacity, 
competence and confidence of remote primary care providers. Utilizing 
weekly video tele-conferencing to create regional communities of 
practice, ECHO links the IPMC specialty teams (i.e. hubs) with their 
designated Patient Centered Medical Homes (i.e. spokes). This improves 
provider knowledge, increases care coordination, and decreases the need 
for continued specialty referrals to the direct and purchased care 
systems. Army Pain ECHO will be available to Providers supporting 
Community Based Warrior Transition Units (CBWTU). Additionally, the 
Army is collaborating with the Air Force, Navy, and Veterans Health 
Administration on development and utilization of a common DOD/VHA Pain 
ECHO education curriculum.

    Chairman Sanders. General Coots, thank you very much.
    Dr. Briggs.

STATEMENT OF JOSEPHINE BRIGGS, M.D., DIRECTOR, NATIONAL CENTER 
FOR COMPLEMENTARY AND ALTERNATIVE MEDICINE, NATIONAL INSTITUTES 
                           OF HEALTH

    Dr. Briggs. Good morning, Chairman Sanders, Ranking Member 
Burr, and Members of the Committee. I want to add my well 
wishes to Senator Boozman.
    Thank you very much for inviting me. I am the Director of 
the National Center for Complementary and Alternative Medicine 
at the National Institutes of Health. NCCAM is the leading 
Federal agency responsible for research on the usefulness and 
safety of complementary and integrative health practices.
    The most common reason Americans turn to these health 
approaches is for treatment of pain. Pain is a major health 
problem affecting over 100 million Americans. It is one of the 
main drivers of our horrific national epidemic of prescription 
drug abuse.
    As a physician, I am well aware that drugs, including 
opioids, are absolutely essential for the management of pain 
but also of their serious side effects including overmedication 
dependency and even death.
    As a Nation, we need to find the appropriate balance 
between the substantial benefits of these medications and the 
risks. Deaths from opioids exceed those attributed to cocaine 
and heroin combined. Every day over 100 Americans die of drug 
overdoses, mostly from prescription painkillers.
    Opioids are particularly deadly when combined with Post 
Traumatic Stress Disorder; and as this Committee knows well, 
pain and PTSD is a common and tough combination faced by many 
veterans, also a very common problem in civilian populations. 
So, finding better alternatives for pain management is an 
absolutely critical national need.
    Concern about research on better strategies for pain 
management is shared by leadership across the NIH. I serve as 
one of the co-directors of the Trans-NIH Pain Consortium and a 
member of the Federal Interagency Pain Research Coordinating 
Committee. Together with other Federal leaders, we are 
partnering to develop a cooperative research strategy to meet 
these important needs.
    Some of the very active areas of NIH research include the 
development of better pain measures including some of the 
measures that have been incorporated by the DOD, the PASTOR 
PROMIS measures, for example, understanding why acute pain 
sometimes turns into chronic pain, and the development of pain 
medications with less abuse potential.
    NCCAM's particular focus is strengthening non-
pharmacological treatment and self-management of pain. The 
evidence that some complementary approaches are of value in 
pain management is reflected in evidence-based guidelines from 
the American College of Physicians and the American Pain 
Society.
    Select practices including meditation, acupuncture, spinal 
manipulation, massage, and hypnosis are increasingly part of 
the kind of integrative care being offered in some of our 
health care settings, including hospitals, nursing homes, 
hospices, and most notably, health facilities in the Veterans' 
Administration and Department of Defense.
    Integrative practitioners place particular emphasis on a 
patient-centered approach that identifies patient goals and, 
when appropriate, minimizes the use of drugs.
    Research on the mechanism and efficacy and safety of these 
approaches is the highest priority for NCCAM. We hope to learn 
how they work, who they help, and how they can be strengthened 
to better help people with chronic pain.
    As part of this effort, we have established a new 
intramural program that will study the biologic underpinnings 
of pain using state-of-the-art neuroscience methods to study 
the brain.
    We are particularly delighted to be embarking on an 
important partnership with the DOD and VA to support the value 
of these approaches to address the needs of military personnel 
and veterans for improvement non-pharmacological management of 
pain together with conditions such as PTSD, depression, and 
anxiety.
    We are funding new studies in partnership with the DOD, VA, 
National Institute on Drug Abuse, and the National Institute on 
Alcohol Abuse and Alcoholism on these important problems.
    We have created a working group of members of NCCAM's 
advisory council to advise us on this research agenda. The 
working group includes distinguished DOD and VA officials such 
as former Army Surgeon General Eric Schoomaker and the VA's Dr. 
Tracy Gaudet. It is chaired by Dr. Lloyd Michener, Director of 
Family Medicine at Duke University.
    In summary, Mr. Chairman, NIH and NCCAM are committed to 
partnerships with the VA and the DOD to strengthen research to 
understand pain, to improve pain management, and reduce 
overmedication and opioid dependency.
    Thank you. I am very happy to be here and happy to answer 
any questions.
    [The prepared statement of Dr. Briggs follows:]
Prepared Statement of Josephine Briggs, M.D., Director, National Center 
  for Complementary and Alternative Medicine, National Institutes of 
          Health, U.S. Department of Health and Human Services
    Chairman Sanders, Ranking Member Burr, and Members of the 
Committee, thank you for inviting me to be here today to discuss the 
need to improve pain management strategies to reduce overmedication and 
opioid dependency. My name is Josephine Briggs, M.D., and I am the 
Director of the National Center for Complementary and Alternative 
Medicine (NCCAM) at the National Institutes of Health (NIH), the 
Federal Government's lead agency for supporting scientific research on 
complementary practices and integrative health interventions. Our 
mission at NCCAM is to define the usefulness and safety of 
complementary and integrative health practices and their role in 
improving health through rigorous scientific investigation. Our 
research priorities are driven by scientific promise and public health 
need. We support the study of complementary interventions, approaches, 
and disciplines across the continuum of basic, translational, efficacy, 
and effectiveness research.
    Complementary, alternative, and integrative health practices are 
defined as having origins outside of mainstream conventional medicine. 
They include both self-care practices like meditation, yoga, and 
dietary supplements, and health care provider administered care such as 
acupuncture, and chiropractic, osteopathic, and naturopathic medicine. 
As these modalities are increasingly integrated into mainstream health 
care, NCCAM is committed to developing the evidence needed by the 
public, health care professionals, and policymakers to make informed 
decisions about their use and integration into medical practice. In 
addition to supporting the research, we disseminate the latest 
evidence-based information on these approaches to scientists, health 
care providers, and the general public through an information-rich Web 
site (www.nccam.nih.gov) and other media.
    According to the Centers for Disease Control and Prevention, 
approximately 30 percent to 40 percent of Americans use complementary 
and integrative health practices, spending some $34 billion in 2007.\1\ 
This represents 1.5 percent of total health expenditures and 11 percent 
of out-of-pocket costs. These practices are increasingly being offered 
in hospitals and hospice settings. The most common reason cited for use 
of complementary and integrative health practices is for the 
alleviation of pain.
---------------------------------------------------------------------------
    \1\ Nahin RL, Barnes PM, Stussman BA, et al. Costs of complementary 
and alternative medicine (CAM) and frequency of visits to CAM 
practitioners: United States, 2007. CDC National Health Statistics 
Report #18. 2009.
---------------------------------------------------------------------------
    Pain is a public health problem of substantial impact. It affects 
more than 100 million Americans each year--more than the total affected 
by heart disease, cancer, and diabetes combined--and is estimated to 
cost the Nation $560-$635 billion each year in medical costs and lost 
productivity.\2\ While an important part of pain management, 
pharmaceutical approaches may provide incomplete relief and can carry 
serious side effects, including overmedication and opioid dependency 
and, in some cases, addiction. Commonly prescribed opioid pain 
relievers can be dangerous as even a single large dose can cause severe 
respiratory depression and death. Deaths from opioid pain relievers 
exceed those attributed to cocaine and heroin combined. Finding 
alternatives for pain management is needed.\3\
---------------------------------------------------------------------------
    \2\ IOM (Institute of Medicine). 2011. Relieving Pain in America: A 
Blueprint for Transforming Prevention, Care, Education, and Research. 
Washington, DC: The National Academies Press.
    \3\ Drug Facts: Prescription and Over-the-Counter Medications, 
National Institute on Drug Abuse, National Institutes of Health, 
May 2013. http://www.drugabuse.gov/publications/drugfacts/prescription-
over-counter-medications, accessed April 28, 2014.
---------------------------------------------------------------------------
    In 2011, after examining pain as a national public health problem, 
the Institute of Medicine (IOM) released a Consensus Report in 2011, 
entitled ``Relieving Pain in America: A Blueprint for Transforming 
Prevention, Care, Education, and Research.'' The IOM report encourages 
Federal and state agencies and private organizations to accelerate the 
collection of data on pain incidence, prevalence, and treatments, and 
to take steps to develop integrative pain management strategies. The 
report notes that ideally, most patients with severe persistent pain 
would obtain care from an interdisciplinary team using an integrated 
approach that would target multiple dimensions of chronic pain--
including disease management, reduction in pain severity, improved 
functioning, and emotional well-being and health-related quality of 
life.
    In addition, the Federal Government created an Interagency Pain 
Research Coordinating Committee (IPRCC) to enhance pain research 
efforts and promote collaboration across the government, to advance our 
fundamental understanding of pain, and to improve pain-related 
treatment strategies. Members include representatives of the 
Departments of Health and Human Services, Veterans Affairs (VA), and 
Defense (DOD), the scientific and medical communities, the public, and 
stakeholder groups. I serve as one of the NIH representatives. The 
IPRCC is developing a comprehensive population health level strategy 
for pain prevention, treatment, management, and research. One of the 
first efforts of the IPRCC was a thorough analysis of pain research 
across Federal agencies, resulting in the recently released ``2011 
IPRCC Federal Pain Research Portfolio Analysis Report'' \4\ which 
revealed many areas of shared research interests between and across 
Federal entities, but no notable redundancies.
---------------------------------------------------------------------------
    \4\ National Institutes of Health, National Institute of 
Neurological Disorders and Stroke, Office of Pain Policy. 2011 IPRCC 
Federal Pain Research Portfolio. Analysis Report. Available at 
iprcc.nih.gov/news/CC_Pain_Portfolio_Analysis_Report.pdf. Accessed 
April 28, 2014.
---------------------------------------------------------------------------
    NCCAM participates in the NIH Pain Consortium to enhance and 
increase the coordination of pain research across NIH. The Consortium's 
efforts include targeted initiatives such as the development of the 
first clinically-based data registry to help identify pain management 
interventions that are most effective for specific patient-types with 
chronic pain, led by the National Institute on Drug Abuse (NIDA), and 
the creation of standard research measures to assess chronic low back 
pain, which was spearheaded by NCCAM.
    To improve pain education in health professional schools, the Pain 
Consortium established 12 Centers of Excellence in Pain Education to 
advance teaching and provide comprehensive curricula about the 
pathophysiology of pain, its assessment, diagnosis, management, and 
treatment. The curricula include the latest research results in 
complementary and integrative pain management, factors that contribute 
to both under- and over-prescribing of pain medications, and how pain 
manifests itself differently by gender, by age, and in diverse 
populations. In addition, NIDA, Medscape Education, and the White House 
Office of National Drug Control Policy developed two continuing medical 
education courses on practical guidance for physicians and other 
clinicians in screening pain patients for substance use disorder risk 
factors before prescribing, and in identifying when patients are 
abusing their medications. The courses use videos that model effective 
communication about sensitive issues, without losing sight of 
addressing the pain. To date, more than 80,000 health care 
professionals have completed these courses.
    At NCCAM, an increasing proportion of our research budget is 
dedicated to studies examining promising non-pharmacological approaches 
for pain management, including mindfulness meditation, spinal 
manipulation, massage, acupuncture, and exercise forms, such as yoga 
and Tai chi. Some of these approaches are already being recommended by 
the American College of Physicians and the American Pain Society in 
their guidelines for the diagnosis and treatment of low back pain. 
NCCAM is interested in better understanding how these interventions 
work, for what type of pain conditions, and the optimal methods of 
practice and delivery. We also support Centers of Excellence for 
Research on Complementary and Alternative Medicine that bring a 
multifaceted interdisciplinary approach to research on pain. In 
addition, NCCAM recently established a new intramural research program 
that focuses entirely on pain using state-of-the-art neuroimaging and 
other advanced technologies to study the mechanisms of pain including 
the role of emotions and attention on the modulation of pain.
    Last year, NCCAM joined NIDA, the National Institute on Alcohol 
Abuse and Alcoholism, and DOD in a joint initiative to conduct research 
on prevention and health promotion interventions to prevent alcohol and 
other drug abuse and associated physical and psychological health 
problems in Veterans and military personnel. NCCAM also issued a 
solicitation, along with NIDA and the VA, specifically focused on 
complementary and integrative approaches to managing pain and other 
symptoms such as posttraumatic stress, Traumatic Brain Injury, 
substance use disorders, anxiety, and sleep disturbances often 
experienced by Veterans and military personnel. The initiative 
requested research approaches to study (a) mind-body interventions such 
as mindfulness- or meditation-based stress reduction approaches, (b) 
yoga, (c) acupuncture, (d) art therapy, (e) massage, and (f) cognitive-
behavioral interventions. Grant applications are currently under 
review, and we look forward to funding multiple studies later this 
year. Research findings from these initiatives are expected to lead to 
enhanced patient care and improved pain and symptom management through 
better integration of evidence-based complementary approaches.
    At my direction, a special Working Group of the National Advisory 
Council on Complementary and Alternative Medicine was recently formed 
to explore ways to foster rigorous research that will inform the use 
and incorporation of complementary approaches in military and veteran 
populations and promote collaboration among the VA, DOD, and NCCAM. The 
Working Group, chaired by Lloyd Michener, M.D., of Duke University, 
includes current and former VA and DOD officials. The group is charged 
with defining a research agenda for mind/body interventions for pain 
and symptom management, including identifying the most promising 
therapies and the next steps for development of large clinical trials. 
Experts will present perspectives of patients, Veterans, military 
personnel, and clinicians to help shape the Working Group's 
recommendations.

    In summary, NIH and NCCAM are committed to improving understanding 
and treatment of pain and related conditions for all Americans 
including military personnel and Veterans. We expect research results 
to provide information to the public and health care providers and 
policymakers. I appreciate the opportunity to appear before this 
Committee, and I look forward to answering any questions. Thank you.
                                 ______
                                 
Response to Posthearing Questions Submitted by Hon. Bernard Sanders to 
Josephine Briggs, M.D., Director, National Center for Complementary and 
          Alternative Medicine, National Institutes of Health
              complementary and alternative medicine (cam)
    Question 1. What can be done to increase long-term programmatic 
research to help better understand CAM therapies and their impact on 
servicemembers and veterans?
    Response. As the Federal Government's lead agency for scientific 
research on complementary practices and integrative health 
interventions, the National Center for Complementary and Alternative 
Medicine (NCCAM) is committed to greater understanding of the 
usefulness and safety of complementary and integrative health practices 
and their role in improving health and health care. Since 2010, NCCAM 
has been working with the Departments of Defense (DOD) and Veterans 
Affairs (VA) to explore opportunities for partnerships and 
collaborations.
    After participating in workshops on complementary interventions for 
pain management with DOD and Post Traumatic Stress Disorder with VA, 
NCCAM issued a Funding Opportunity Announcement (FOA) in 2012, to 
encourage collaborations with DOD and VA researchers and clinicians to 
study integrative approaches to pain and symptom management in military 
and Veteran populations. Under this initiative, seven collaborations 
were funded to study modalities such as massage, acupuncture and 
chiropractic for musculoskeletal pain and post-traumatic headache, as 
well as Tai Chi and mindfulness for treating stress disorders, anxiety, 
and depression. In 2013, NCCAM participated in a FOA with the National 
Institute on Drug Abuse (NIDA) and DOD, to promote research on 
interventions to prevent alcohol and other drug abuse and associated 
physical and psychological health problems in military personnel and 
Veterans. NCCAM funded two research projects under this FOA, both 
involving the study of innovative interventions for pain management and 
to reduce substance abuse.
    Last year, NCCAM issued three FOAs, along with NIDA and VA, to 
encourage research on the non-pharmacological management of pain and 
co-morbid conditions in military personnel and Veterans. NCCAM has 
committed two million dollars in Fiscal Year 2014, and hopes to fund 
studies exploring a variety of complementary interventions for pain 
management, including combined interventions for treating pain and 
substance abuse, bright light treatment, mindfulness training, and the 
use of mobile neurofeedback applications for pain management.
    To guide future collaborative efforts with DOD and VA, NCCAM 
recently established a special Working Group of the National Advisory 
Council on Complementary and Alternative Medicine. The Working Group is 
charged with advising NCCAM on potential collaborations, opportunities 
and strategies for integrative health research within DOD and VA health 
care settings. Invited experts will present perspectives of patients, 
military personnel and Veterans, clinicians, researchers, and 
policymakers to inform the Working Group in shaping its final 
recommendations. The Working Group is expected to submit a report to 
the National Advisory Council for Complementary and Alternative 
Medicine in early 2015.
    NCCAM looks forward to building on current collaborations and 
continuing to partner with other NIH Institutes and Centers, DOD, and 
VA to further investigate the usefulness and safety of complementary 
and integrative health interventions for servicemembers and Veterans.

    Question 2. A challenge of medical research is the length of time 
it takes for research to move from bench to bedside. What is the 
National Center for Complementary and Alternative Medicine doing 
specifically--and NIH more generally--to expedite this process?
    Response. NCCAM is committed to improving the translation of 
research findings into improved public health. At NCCAM's core is a 
vision in which rigorous scientific evidence about complementary health 
practices informs both the decisions Americans make regarding the use 
of these health practices and their potential integration into health 
care. As such, NCCAM funds research across the continuum of basic, 
translational, efficacy, and effectiveness research. As part of our 
translational portfolio, NCCAM supports research required to design and 
implement definitive clinical research and ``real-world'' outcomes and 
effectiveness research that capitalizes on the reality that many 
complementary health interventions are in widespread public use. This 
research includes identifying and validating biomarkers or other 
signatures of biological effect; developing and validating measures of 
outcome; validating treatment algorithms and measures of quality 
control; and developing preliminary clinical evidence.
    Additionally, NCCAM is leading the Health Care Systems Research 
Collaboratory, an NIH Common Fund initiative. This program is engaging 
health care delivery organizations as research partners, with the goal 
of strengthening the national capacity to conduct rigorous large-scale 
clinical trials in ``real-world'' settings. Through the Collaboratory, 
NIH is pioneering the development of approaches to conduct large-scale, 
cost-effective clinical research studies in the setting where patients 
already receive their care. Ultimately, this program could help 
increase the number and types of health care systems engaged in 
clinical research and enhance the relevance of research results to 
health care practice.
    At the bedside-end of the continuum, NCCAM ensures that research 
results are widely disseminated to help the public make informed 
decisions about the use of complementary health practices and to enable 
health care providers to better manage patient care. NCCAM provides 
reliable, objective, and evidence-based information through a variety 
of approaches including emerging technology and platforms (i.e., video, 
social media, and mobile applications). Specifically for health care 
professionals, NCCAM's web site features a portal with links to 
scientific literature on complementary health practices, including 
reviews from the Cochrane Collaboration; clinical practice guidelines 
issued by third-party organizations; and online continuing education 
modules. In addition, NCCAM's monthly e-newsletter, NCCAM Clinical 
Digest, summarizes the state of the science on complementary health 
practices for specific health topics.
    Across the NIH, many NIH Institutes and Centers and trans-NIH 
initiatives are also focused on expediting the process of turning 
observations in the laboratory and clinic into effective interventions 
that improve the health of the individual and the public--from 
diagnostics and therapeutics to medical procedures and behavioral 
changes. For example, the newest Center at NIH, the National Center for 
Advancing Translational Sciences (NCATS) was established to transform 
this process by catalyzing the generation of innovative methods and 
technologies that will enhance the development, testing, and 
implementation of diagnostics and therapeutics across a wide range of 
human diseases and conditions. Advances from NCATS are aimed at 
enabling researchers throughout the public and private sectors to more 
efficiently develop treatments for diseases, demonstrate effectiveness 
in improving health, and accelerate the pace at which new treatments 
are delivered to patients.
                              opioid usage
    Question 3. How can collaborative efforts, such as the Interagency 
Pain Research Coordinating Committee, be leveraged to reduce the 
American health care system's dependency on high-dose medications to 
reduce chronic pain and mental health conditions?
    Response. Collaborative efforts across the National Institutes of 
Health (NIH) and the Federal Government to increase the understanding 
of pain are helping to enable the development of novel therapies, 
including non-pharmacological approaches to treat those who suffer from 
pain conditions. Better strategies for the management of chronic pain 
may also reduce symptoms associated with some mental health conditions, 
such as depression and anxiety that are often comorbid with pain.
    The Interagency Pain Research Coordinating Committee (IPRCC) was 
created to enhance pain research efforts and promote collaboration 
across the Federal Government, with the ultimate goal of advancing 
fundamental understanding of pain and improving pain-related treatment 
strategies.\1\ The Committee comprises seven Federal members and 12 
non-Federal members, six drawn from the scientific and medical 
communities and six from public and stakeholder groups. Six Federal 
Agencies are involved in this effort.\2\ NCCAM is one of the NIH 
representatives.
---------------------------------------------------------------------------
    \1\ http://www.iprcc.nih.gov
    \2\ DOD, VA, and within HHS, NIH, the Agency for Healthcare 
Research and Quality, the Centers for Disease Control and Prevention, 
and the Food and Drug Administration.
---------------------------------------------------------------------------
    The IPRCC conducted a thorough analysis of the Fiscal Year 2011 
Federal pain research portfolio and released a report that identified 
areas for potential collaboration among the IPRCC- represented 
agencies. The analysis and accompanying report provide important tools 
to assist in sharing resources across the pain research community and 
for enhancing pain research efforts. For example, the Office of Pain 
Policy at NIH's National Institute on Neurological Disorders and 
Stroke, under the auspices of the IPRCC, launched the Federal 
Government's pain research database on May 27, 2014. This resource 
provides the public and the research community with an important tool 
to learn more about the breadth and details of pain research supported 
across the Federal Government.
    The IPRCC is also charged with developing the National Pain 
Strategy, a comprehensive population health level strategy for pain 
prevention, treatment, management, and research. One objective of the 
strategy is to describe how efforts across Government agencies, 
including public-private partnerships, can be established, coordinated, 
and integrated to encourage population-focused research, education, 
communication, and community-wide approaches that can help reduce pain 
and its consequences. The development of the National Pain Strategy 
will involve coordination between the IPRCC and the NIH's Pain 
Consortium, as well as private-sector participants.
    Within the NIH, the NIH Pain Consortium helps coordinate and 
support a number of pain research initiatives and activities across the 
NIH. Importantly, the Pain Consortium is cosponsoring a workshop with 
the NIH Office of Disease Prevention to address several issues related 
to pain management, including the long-term effectiveness of opioids 
for treating chronic pain and the use and effectiveness of opioid 
management strategies in minimizing opioid addiction, abuse, and 
misuse, maximizing pain relief, and improving patients' quality of 
life. Based on the evidence presented, an independent panel of experts 
will release a comprehensive report in early 2015 on the state of the 
evidence, identifying research gaps and proposing research priorities.
    The efforts of the Pain Consortium have already made an impact. On 
May 21, 2014, NIH announced that the NIH Pain Consortium's first pain 
care curriculum--part of the 12 ``Centers of Excellence in Pain 
Education''--showed significant improvements in medical student 
clinical skills.\3\ The educational materials are designed to advance 
the assessment, diagnosis, and safe treatment of pain, while minimizing 
risks of abuse and addiction. The curricula include the latest research 
results in complementary and integrative pain management, factors that 
contribute to both under- and over-prescribing of pain medications, and 
how pain manifests itself differently by gender, by age, and in diverse 
populations. In addition, NIDA, Medscape Education, and the White House 
Office of National Drug Control Policy developed two continuing medical 
education courses on practical guidance for physicians and other 
clinicians in screening pain patients for substance use disorder risk 
factors before prescribing, and in identifying when patients are 
abusing their medications. The courses use videos that model effective 
communication about sensitive issues, without losing sight of 
addressing the pain. To date, more than 80,000 health care 
professionals have completed these courses. These efforts will help 
current and future health care professionals build clinical skills to 
better support, manage and treat patients with pain.
---------------------------------------------------------------------------
    \3\ http://www.nih.gov/news/health/may2014/nida-21.htm
---------------------------------------------------------------------------
                                 ______
                                 
  Response to Posthearing Questions Submitted by Hon. Mark Begich to 
Josephine Briggs, M.D., Director, National Center for Complementary and 
          Alternative Medicine, National Institutes of Health
    Question 4. I know I hear from Veteran's in my state that ask for 
more alternative methods for pain, PTSD and with our large native 
population, many native veterans rely on native healers, in the Native 
Health Care system, they are called doctors. Have you researched the 
use of Native healing and if not will you be looking at this effective 
method of healing?
    Response. NCCAM is committed to studying the usefulness, safety and 
efficacy of complementary and integrative health approaches, many of 
which have origins in traditional healing practices. Although a wide 
variety of these practices are used by the American public, better 
information is needed on how or whether they work.
    According to the Centers for Disease Control and Prevention, over 
50 percent of American Indian/Alaska Native (AI/AN) adults use 
complementary therapies--greater than any other ethnic group.\4\ Given 
the prevalence of complementary therapies among this population, 
research on native healing practices is important, and NCCAM takes a 
number of approaches to encourage such research. For example, NCCAM is 
interested in research projects utilizing systems of healing and health 
practices outside the conventional medical care and those studying the 
extent and use of self-care and integrative health practices, 
conventional medical care, or a combination of the two. Examples of 
NCCAM funded research projects include:
---------------------------------------------------------------------------
    \4\ Barnes PM, Bloom B, Nahin R. CDC National Health Statistics 
Report #12. Complementary and Alternative Medicine Use Among Adults and 
Children: United States, 2007. December 2008.

     ``Drum-Assisted Recovery Therapy for Native Americans,'' 
Daniel Lee Dickerson, D.O., MPH, University of California, Los Angeles. 
Dr. Dickerson' grant focused on developing and pilot testing a 
treatment approach that included Drum Circles and the 12-steps of 
Alcoholics Anonymous within the conceptual framework of the Native 
American Medicine Wheel.
     ``Chemopreventative Properties of Medicinal and Food 
Plants of the Lumbee Tribe,'' Tracie Locklear, Ph.D., University of 
Illinois, Chicago. Dr. Locklear's grant supported her research on the 
development and testing of natural agents isolated from medicinal and 
food plants of the Lumbee Tribe. The long term goal of the project was 
to develop new and novel natural agents for the chemoprevention of 
breast cancer.

    In addition, NCCAM participates in the Native American Research 
Centers for Health (NARCH),\5\ which is a partnership between the 
Indian Health Service and NIH. The goal of the NARCH program is to 
provide opportunities for tribes and tribal organizations to conduct 
research, research training, and faculty development that meet the 
needs of AI/AN communities.
---------------------------------------------------------------------------
    \5\ http://www.nigms.nih.gov/Training/NARCH/Pages/default.aspx
---------------------------------------------------------------------------
                                 ______
                                 
   Additional Information from Josephine P. Briggs, M.D., Director, 
  National Center for Complementary and Alternative Medicine, Public 
             Health Service, National Institutes of Health

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


    Chairman Sanders. Dr. Briggs, thank you very much.
    Let me begin with Dr. Petzel. Dr. Briggs, I think 
appropriately, talked about this issue as an epidemic. We have 
a horrific problem in Vermont but I think it is shared in 
States throughout this country. People overdosing, getting 
addicted, turning to crime, self-destruction. It is an awful 
issue.
    As we know, as bad as this problem is for the civilian 
population, it is likely even worse among our military and 
veteran population, largely because of the nature of the 
injuries and conditions they experience.
    Dr. Petzel, first, how serious is the problem you are 
addressing and second--Dr. Gaudet and maybe Dr. Marshall might 
want to join in--tell me the role that you think complementary 
and alternative medicine can play in addressing those problems.
    Dr. Petzel. Thank you, Mr. Chairman.
    First of all, in terms of the magnitude of the problem, 
several have mentioned it. We estimate that 50 percent of 
veterans that are coming to us seeking care have some sort of 
pain. Much of it is musculoskeletal, back injuries, et cetera, 
associated with the work that a soldier, sailor, airman, and 
Marine may be doing.
    We are prescribing opioids for somewhere around 650,000 
veterans at the present time which is a large number of people, 
and we recognize the fact that this is an issue that has to be 
addressed very directly.
    I would like to just take a minute before I turn to the 
other panel members to describe the opioid safety program that 
we are involved in to try and get a grip on and reduce the use 
of opiates which, by the way, has reduced the number of 
patients receiving opioids in the last 18 months by 50,000. 
Still, there are a lot of people getting it but----
    Chairman Sanders. So, 50,000 fewer veterans are now 
receiving opioids?
    Dr. Petzel. That is correct.
    The five things that are the central part of the pain 
management program are: one, every medical center has to have a 
pain management clinic; two, every medical center has a pain 
consultation service. VA requires the use of integrative CAM 
approaches.
    The details of this--we require the use of the step care 
model which was developed in the VA and I think has been 
adopted by the Department of Defense now which begins with, in 
the primary care clinic, self-management and management in 
primary care of pain. If needed, it moves to the secondary pain 
clinic; and then finally, there are tertiary pain services 
available.
    The centerpiece of this, though, is the opioid dashboard, 
monthly report to the facilities, to the providers in the 
facility, and to the pain management point of contact about 
people that are prescribing outside of the standard and 
patients that are taking medication outside of the standard.
    That is followed by education and discussion and 
consultation with the providers to bring their use of opioids 
into the standard.
    Chairman Sanders. OK. If I can interrupt you, we will take 
a little bit more time for everybody, because we only have four 
of us here. But I wonder--if it is OK with you, Dr. Petzel, I 
wanted to shift over to Dr. Gaudet and Dr. Marshall.
    What are you doing with complementary and alternative 
medicine and is it, in fact, working?
    Dr. Gaudet. Thank you, Chairman Sanders.
    I think you are aware that the vision for health care, as 
Ranking Member Burr referenced, is personalized proactive 
patient-driven; central to that are strategies that are 
inclusive of complementary approaches that empower the veteran 
to take into their own hands whether they have pain issues. Of 
course, this expands far beyond pain to the many, many 
conditions facing veterans and the public, complex conditions 
where a simple fix does not exist.
    So, I think that these areas, particularly pain, are 
phenomenal places where the VA is committed to bringing more 
holistic approaches to veterans. The veterans are finding them 
very empowering, very much an asset to the complement of what 
they can do to address their issues of pain as well as other 
issues. Yes sir.
    Chairman Sanders. In English.
    Dr. Gaudet. Yes, sorry.
    Chairman Sanders. What are you offering the patient? So, 
somebody walks in. They have chronic pain. They are concerned 
about overmedication. You are concerned. What therapies are you 
offering and are they, in fact, working?
    These are fairly radical ideas in a certain sense, yes? Or 
not?
    Dr. Gaudet. I do not know how radical they are, but I think 
that the therapies that are most promising and most often 
utilized right now in the VA are very parallel to the DOD and 
the public.
    So, they tend to be mind-body approaches such as 
meditation, acupuncture, movement therapies such as, yoga, tai 
chi, spinal manipulation. These are the general approaches that 
seem to have the greatest promise--relatively noninvasive and 
at low risk.
    Chairman Sanders. Now, I have been impressed. I have been 
to VA facilities all over the country and I have been to a 
couple of DOD facilities and I am amazed. You know, 20 or 30 
years ago I think it is fair to say that if we were talking 
about this list of therapies, people would have thought there 
were a few folks in California or certain other places 
utilizing them, not the U.S. Department of Defense or VA.
    So, in terms of treatments like acupuncture, are they 
working? What can you tell us about your success rates? Does it 
work?
    Dr. Gaudet. I think the most evidence actually exists for 
acupuncture as it relates to pain. Our research office of 
evidence-based synthesis just finished a comprehensive look at 
all the evidence related to acupuncture. It is a very useful 
document because it basically says where is there evidence for 
the use of acupuncture, do we know, and is it of benefit or do 
we know it is not of benefit or there is a category where we 
just do not know yet, we do not have research.
    The areas where there is the best and strongest evidence 
for acupuncture are pain, chronic pain, headaches, and 
migraines. So, it is a rational place to start.
    Chairman Sanders. All right. Dr. Marshall, if I walk into 
your beautiful facility in Minneapolis, and I was just there a 
few days ago, and I am in pain, what are my options other than 
drugs?
    Dr. Marshall. Mr. Chairman, thank you for that question.
    I would say at Minneapolis we view pain management as a 
full-spectrum opportunity to engage with a patient and move 
them toward a healthier and more functional life.
    So, we have deployed various complementary and alternative 
modalities at different levels of our facility. For instance, 
nurses, we trained 900 nurses in January of this year; a 4-hour 
training in complementary and alternative medicine with 
integrative nursing.
    Modalities that we trained specifically to those nurses 
included acupuncture, relaxation breathing, meditation, and 
essential oils or aroma therapy.
    Chairman Sanders. When you tell your patients these 
therapies are available, do they say, hey, I would like to try 
that? What do they say?
    Dr. Marshall. There is a lot of variability. Some patients, 
you know, express a strong desire for opioid pain medications. 
Many patients, though, are very open once they learn that these 
alternatives are a standard part of our medical treatment 
armamentarium at Minneapolis VA. I think many patients are 
gravitating toward these kind of services.
    Chairman Sanders. Can you tell us some success stories? Are 
there people who have lived with pain, who were heavily 
medicated but because of complementary and alternative medicine 
have been able to get rid of medication? Dr. Marshall, do you 
have stories?
    Dr. Marshall. Yes, I would like to talk briefly about a 
program that we have just started. This is part of the VA's 
efforts to have Council for Accreditation of Rehabilitation 
Facilities, CARF, pain rehab center at each VISN. So, we 
started one in January of this year.
    We recruited the Director of the Mayo Clinic Pain Rehab 
Program who is now leading our efforts. So that program which 
is just starting at Minneapolis VA had seven veterans, four of 
them were on opioids, three of them were tapered off, and one 
was tapered down.
    And a cornerstone of that program is a 3-week intensive 
residential program and a cornerstone of that program is 
activating patients' innate healing abilities through use of 
primarily complementary and alternative modalities, including 
cognitive behavioral therapy, meditation, relaxation breathing, 
tai chi, yoga, and other active forms.
    Chairman Sanders. So, you have some specific indications 
that these therapies are working?
    Dr. Marshall. Yes.
    Chairman Sanders. OK. I have exceeded my time.
    Senator Burr.
    Senator Burr. Thank you, Mr. Chairman.
    Dr. Petzel, just one follow-up to this hope that we get a 
pathway on Phoenix to some facts. When we had one death at the 
Columbia VA medical center that was related to delays, when the 
medical center and the VISN leadership became aware of that 
problem there were four outside reviews, specifically the task 
force, the Office of Medical Inspector, and the IG.
    Are you confident that we have the sufficient focus on 
Phoenix for this Committee and for the VA to understand what, 
if anything, went wrong?
    Dr. Petzel. Senator, I am. I think that the IG's presence, 
the inspector general, with their independent look, and they 
have a huge collection of manpower that they are focusing.
    Senator Burr. What would trigger so many components for 
Columbia on one death versus just the IG on this?
    Dr. Petzel. I really cannot answer that. I do not know. We 
sent our team in. I think the IG actually went in twice. I 
really cannot speak specifically to what they did. But I am 
confident that the IG has the resources and has them present in 
Phoenix to get to the bottom of what has occurred there.
    Senator Burr. OK. Dr. Gaudet, let me ask you. Is it easier 
to write a prescription or to try a CAM approach?
    Dr. Gaudet. It is easier to write a prescription.
    Senator Burr. Yes. Can you envision, any of you from the 
VA, that it would be appropriate to prescribe an opiate to 
somebody who, in their medical records, has an opiate 
addiction?
    Dr. Gaudet. I am probably not the best person to answer 
that, not being a pain doctor.
    Senator Burr. Dr. Marshall?
    Dr. Marshall. I think the indications would be extremely 
rare. It would be very unusual to do that, but it might be done 
in certain situations, especially situations around acute pain 
from trauma after an operation.
    Senator Burr. So, for a veteran with an opiate addiction 
being treated by VA and sent home for the weekend with 19 
prescriptions, including 12 tablets of oxycodone, and 3 hours 
later he dies of a drug overdose; that would be an unusual 
circumstance?
    Dr. Marshall. I would concur with your previous statement 
that one death too many. It should not happen.
    Senator Burr. Dr. Petzel, VA issued a pain management 
directive in 2009 and in a House Veterans' Affairs Committee 
hearing last fall on the issue, Dr. Jesse said that all VISNs 
and VA facilities have implemented a pain management directive. 
Yet data obtained by the Center for Investigative Reporting 
shows, ``VA doctors are prescribing more opiates than ever and 
the data suggests adoption of the directive varies widely.''
    This is not the only time we have heard problems about 
regulations and programs being executed inconsistently across 
the VA. What oversight does the VA central office perform to 
make sure that the new programs and directives issued are 
implemented as intended?
    Dr. Petzel. Thank you, Senator Burr.
    One, the opioids safety initiative is intended to 
standardize the way we approach. Two, we have demonstrated that 
opioid prescribing in the VA has actually decreased, as I 
mentioned earlier, by 50,000 in the last approximately 18 
months; and we expect to see that plummet. Number 3----
    Senator Burr. We put this management plan into effect in 
2009 and we had an upward spike. You will agree to that?
    Dr. Petzel. Yes.
    If I could digress for a minute. In this country in 
general, not just the VA, there was 10-15 years ago a feeling 
that pain was not being adequately managed, and an effort was 
made to educate doctors about using opioids and other things to 
adequately manage pain, and I think in this country there was 
an overreaction to that phenomenon. And that is part of why we 
are involved in this effort to try and get a grip on opioid 
prescribing and to aggressively pursue other approaches to 
managing pain. While I was not here at the time, my suspicion 
is that that was part of what was going on within the VA.
    Senator Burr. Well, I think Dr. Gaudet reinforced, I think, 
our belief, and I think it is the fact that it is easier to 
write a prescription than it is to go through a CAM process; 
and I think Dr. Briggs would probably agree with me.
    There are some medical conditions that we probably will not 
be able to use an alternative for. The pain is real. It is 
consistent. It can only be addressed with some type of opiate 
medication or alternative to an opiate. For those people, they 
usually fall into a category of a specific illness that they 
have. Certainly, we do have some servicemembers that fall into 
that category.
    Here is my concern, Dr. Petzel, and my question is this, 
when people do not follow the guidelines set by VA--be it a 
doctor, nurse, whoever--what tools do you have to hold them 
accountable?
    I mean, we have seen difficulty with sterilization of 
medical devices. You and I have seen where insulin injection 
pens--multi-use injection pens--that we have now made a 
determination that we are not going to use them at the VA 
anymore because we----
    Dr. Petzel. No, they are not used in-patient. They are 
very, very deeply used as outpatients. They are great.
    Senator Burr. Why do we not use them in-patient?
    Dr. Petzel. Because of the possibility that there might be 
confusion, as we talked about.
    Senator Burr. Because we cannot with certainty believe that 
it is being executed by those guidelines, which means you 
cannot stick a different person with the same pen.
    So, if something that simple is tough to do, what gives us 
confidence that we can carry out a pain management directive 
successfully or any other directive within the health care 
system?
    Dr. Petzel. Senator Burr, I would point out that the opioid 
dashboard is our tool for monitoring the prescriber's use of 
opioids. And the first step when somebody is not using these 
appropriately is to educate them about the way that it ought to 
be done properly.
    So, do we have the tools to correct behavior that we think 
needs to be modified? Absolutely yes.
    Senator Burr. OK, Mr. Chairman. Thank you.
    Chairman Sanders. Thank you.
    Senator Begich.

                STATEMENT OF HON. MARK BEGICH, 
                    U.S. SENATOR FROM ALASKA

    Senator Begich. Mr. Chairman, thank you very much. I know 
earlier you talked about the issue in Arizona so I just want to 
know that--assuming that as soon as the IG report comes, and I 
know, Mr. Chairman, you noted that we will have some sort of 
process here. Obviously, we will look forward to that.
    The question that I am going to be very interested in, and 
it can be answered now or later, and that is the issue of the 
information that the Arizona VA was sending to the national, 
whatever the information was on appointment status; in other 
words, how long it took people to come through their 
appointments--that information. Was that correct or were there 
issues with it. That is going to be my question.
    There are a lot of details of deaths and so forth. What I 
want to know is did the information that came from the VA in 
Arizona to the national--who keeps track of successes at the 
different VAs and the amount of backlog and appointment 
scheduling--on those metrics, will that report or other reports 
confirm accuracy in the delivery of that information. That is 
going to be my fundamental question.
    Dr. Petzel. Senator Begich, as I mentioned earlier, we had 
a team down there looking in a preliminary fashion at the 
circumstances in Phoenix, and to date we have not found that 
there is any discrepancy between the information that we were 
aware of and were getting and the information as it actually 
existed in Phoenix.
    We have found no evidence for a secret list and we have not 
found any evidence to-date that anybody died while sitting on 
the waiting list.
    Senator Begich. Understood. And the IG is looking at all 
those questions I am assuming?
    Dr. Petzel. Yes, they are; as near as I know, yes.
    Senator Begich. OK. And I apologize. I know this part was 
answered. What is their timetable? Do you know?
    Dr. Petzel. They have not shared that with us, so I do not 
know.
    Senator Begich. OK. We will probably hear details as time 
moves on.
    Dr. Petzel. I hope.
    Senator Begich. OK. Thank you. I missed one meeting--I 
cannot remember if I was here or at the Appropriations 
Committee--but I wanted again to commend you all for working on 
and reviewing the NUKA model in Alaska.
    We think this is--as we talk about overmedication and many 
other things--I think they have really capitalized on a very 
unique model that is looking at the whole body and all people 
engaged in health care. One of the things that I want to ask 
is, I am assuming in this issue today that we are talking 
about, overmedication, as you look at the NUKA model you will 
be also looking at this piece of the equation.
    For example, I know they use not only alternative medicines 
but they also use through the native health care, native 
healing methods. Is that also something as you look at the NUKA 
model you can be examining because I want to make sure that is 
part of the equation.
    Dr. Petzel. My understanding, Senator Begich, is the 
central feature of the NUKA model is listening to the patient's 
story and then crafting the therapy around that individual 
patient's story and their circumstance. Since it is an Alaskan 
native program, those medicines, et cetera, are woven 
intimately into the way they deliver care.
    In the Native community here in the States where the VA is 
dealing, we also employ native healers, et cetera, and those 
concepts in dealing with that particular patient population. 
But I think Dr. Gaudet can maybe comment briefly on the fact 
that that is a tone that goes through our program.
    Dr. Gaudet. Yes, thank you, Senator. I would certainly just 
underscore the importance of this holistic approach which I 
appreciate your question actually brings to the surface.
    I think the challenge before us really--truly not just in 
VA health care but nationally in the model of health care that 
is dominant in this country--it is so much easier to write a 
prescription, as Ranking Member Burr said.
    The system is designed to do that. We as physicians are 
trained to find it-fix it. I can operate and I can write you a 
prescription and anything outside of that--and this is a slight 
exaggeration--but I am not actually trained to think about or 
understand.
    So, this transformation is a huge system change, and it 
does as you have described and as Dr. Petzel has described, 
begin with understanding the person. If we are in a situation 
such as Senator Boozman, thank goodness we have the high-tech 
approach. Perfect. They can go in. We can sew you up. We can 
fix the problem.
    Senator Begich. Right.
    Dr. Gaudet. But in the myriad of things like pain, like 
obesity, like PTSD, those find it-fix it cures do not exist. 
So, this holistic approach starting with the individual, 
understanding their cultural beliefs and creating a 
personalized approach for and with them is absolutely 
essential.
    Senator Begich. Very good. Let me proceed, if I can, 
because I have limited time here. General, I know the Army and 
TRICARE have recently required mental health counselors to our 
veterans be credited through the Council for Accreditation of 
Counseling Related Educational Programs.
    Here is the challenge in Alaska. We do not have the 
capacity to meet those standards because of the uniqueness of 
Alaska. It is not offered in Alaska, so it makes it difficult; 
and with huge gaps in mental health professional numbers, how 
can we go with this when in reality we have vacancies that we 
should fill which can easily be filled with qualified 
counselors. But how are we going to meet this in Alaska?
    I mean, I know everyone likes a one-size-fits-all solution. 
Those do not work in Alaska. I will tell you there is no better 
health care as what the VA is looking--Indian Health Services--
no better health care delivery system in the country. So, we 
figured out how to do it and it does not come from a national 
model. It does not come from the standards that people sit 
around and make up.
    I mean, we deal with reality. That is why we have a great 
dental program in the Indian Health Services. You know, the 
dental community does not necessarily like it totally, 
nationally, but it works in Alaska because we have remote areas 
and we have huge tooth decay and other things that we have been 
able to accomplish through dental therapists.
    So, how are we going to handle this?
    Chairman Sanders. In 24 seconds.
    General Coots. Yes, sir. Alaska is known for its use of 
tele-medicine initiatives, and I think that for the military 
utilizing tele-behavioral health is probably one of the biggest 
initiatives that we have in serving areas that are remote or 
where we do not have those health care providers.
    We are looking at some different ways of attracting 
additional behavioral health providers. We are also looking at 
training some of our own. As we draw down the military, we have 
a large core of physicians assistants that we are looking at 
retrainings some of them as behavioral health physicians' 
assistants.
    Senator Begich. Very good. Let me say, Mr. Chairman, I have 
a couple of cases which I am going to send to Dr. Petzel and 
maybe some very specific questions on how we would respond to 
these kind of individuals that deal with medication.
    Thank you very much.
    Chairman Sanders. Thank you, Senator Begich.
    Senator Isakson.
    Senator Isakson. General Coots, first of all, thank you for 
your service particularly at Walter Reed. You all performed 
miracles on a daily basis in rehab for our servicemen. We 
appreciate it very much.
    I know Colonel Galloway's responsibilities are 
rehabilitation and reintegration of DOD active duty troops back 
into society I take it or back into the military?
    General Coots. Both.
    Senator Isakson. Which tells me that opiate 
overprescription is probably as big a problem in DOD as it is 
in veterans' health care. Is that correct?
    General Coots. Sir, I would say we have statistics that 
show that up until about 2011, about 26 percent of all active 
duty were on some level of opioid medications, either one 
single opioid or multiple opioids.
    The Army is traditionally a little bit higher, 2 or 3 
percentage points higher, I think, by the nature of what we do 
and the pain that our servicemembers have from repeated combat 
tours in remote areas.
    But all the statistics are showing now that with a big push 
for cultural change, with integration of these alternative 
medical modalities, that we are seeing a downturn in opioid use 
across the military, particularly across the Army, and then a 
large upswing from 10 percent up to 28 percent now, utilizing 
alternative medicine.
    Senator Isakson. Which is my point because, you know, we 
use DOD for all kinds of medical research: breast cancer, 
prostate cancer, things like that because you have a controlled 
environment. You have people who are not necessarily 
voluntarily participating but they are participating because it 
is their job. We get a lot of medical data.
    I guess we have learned from addiction and opioid overuse 
that the ``settled science'' is there in terms of what 
constitutes an addiction or an overuse. What we are trying to 
do is find out how we deal with it, and once it happens, to 
prevent it from happening again. Is that right?
    General Coots. Yes, Senator, that is correct.
    Senator Isakson. Then that brings me to my question. 
Seamless transition from DOD health care to veterans health 
care, which by the way General Schoomaker did a remarkable job 
of improving in his service at Walter Reed and in the military.
    What is DOD doing as these active duty military personnel 
go into veteran status? What is the transition like 
particularly with regard to opiates and then opiates having 
been prescribed, of them having been addicted? Is there a 
program or do they go into a black hole and the VA just has to 
discover the problem all for themselves?
    General Coots. Senator, that is a good question. I will 
answer it in two parts.
    First, we have a shared formulary where we have lined up 
the formulary so that any medications that a military member 
might be on, as they transition into the veterans health care 
system, that same medication or modality is available to them 
in the transition.
    We also are working on improving our warm handoff such that 
our military servicemembers have a lead coordinator. There is a 
corresponding lead coordinator on the VA side so that their 
information is transmitted directly in a handoff from that 
military lead coordinator to the VA system so that all of the 
associated and ancillary modalities that have treated them for 
whatever their problems are, be it opiate, be it anything else, 
all of those will transfer over so there is a knowledge 
transfer.
    So, there is no falling off in the cracks or going into a 
black hole.
    Senator Isakson. Good. Good.
    Dr. Marshall, the opioid safety initiative started in 
Minneapolis, is that right?
    Dr. Marshall. That is correct, Senator.
    Senator Isakson. If you uncover a provider who is not 
following the proper safety administration of opioid 
prescriptions, what training or what follow-up do you require 
to make sure that they do not do it again, or is there a 
prescription for doing that?
    Dr. Marshall. Well, first of all, Senator, thank you for 
that question because I think it is an integral part of what is 
happening at Minneapolis. So, we are building a standard of 
care and a cultural change in how we prescribe opioids.
    Part of it is building the prescribing of opioids into a 
team setting so we are using the providers who are doing the 
prescribing, the pharmacists who bring their unique skill set 
to the primary care team to help monitor for adverse effects 
or, you know, dosage problems, and also mental health. So, a 
lot of the control happens at that point working with the 
patient and the primary care team.
    Another phase of the accountability process is that we have 
transparent data--the dashboard that Dr. Petzel mentioned. So, 
we are using that to understand who are the outlying 
prescribers who need more help with changing their prescribing 
patterns.
    And the final stage of accountability rests with the chief 
of staff who, at our facility, has been very involved in 
providing specific direction to providers who are outside of 
the standard of care.
    So, it is a supportive system but there are levels of 
accountability.
    Senator Isakson. Dr. Petzel, you are familiar with our 
question with regard to suicide in the Atlanta VA, and I 
appreciate very much your attention to the ongoing initiative 
there.
    But it occurred to me that in the Atlanta VA situation 
where there were four instances now taking place over the last 
year, two of those were non-drug addicted Vietnam-era, 
noncombat veterans, meaning that they were veterans who served 
during the Vietnam era--my age group, in their late 60s or 
early 70s. They were not in combat. They did not transition 
from DOD to VA health care recently. They did it over a long 
period of time.
    I worry sometimes that prescribing opiates to mental health 
patients who come in for their first encounters at VA 
prescribing opiates might mask a greater problem or might 
accelerate a problem that exists.
    Is there any disciplinary requirements within the VA as far 
as mental health encounters are concerned in terms of 
prescribing opiates?
    Dr. Petzel. Senator Isakson, that is an excellent question. 
There are certain antecedents that are frequently found in 
patients who have either attempted suicide or actually 
committed suicide. Depression, PTSD, sleep disorders, and pain. 
Pain is often an antecedent to suicide, particularly chronic 
pain.
    So, the mental health provider is attuned to the fact that 
when they see somebody who is new to them that they need to be 
evaluated for those antecedents to be sure that they are taken 
into account when they begin to write prescriptions.
    So, anybody who has mental health problems who then also 
presents with a pain problem requires and gets very special 
attention.
    Senator Isakson. Thank you.
    Thank you, Mr. Chairman.
    Chairman Sanders. Thank you, Senator Isakson.
    Senator Blumenthal.
    Senator Blumenthal. General Coots, you mentioned a 
statistic before which I missed as to the percentage of use of 
opioids. I think that was the percentage in the Army or the 
military. Could you repeat that?
    General Coots. Yes, Senator. Up to 2011, the number was 
about 26 percent of all active duty had been prescribed at 
least one opioid medication.
    Senator Blumenthal. And that could be in the course of the 
individual soldier's entire service? Or over what period of 
time?
    General Coots. We are actually tracking that on a year by 
year basis, watching it; and over time, say, from 2007 to 2011, 
you saw a steady increase up to that 26 percent point. After 
about 2011 over the last 2 years, going on almost 3 years, we 
have seen a steady drop off, either stabilization or decline in 
the numbers that are using it.
    Senator Blumenthal. So, let us take 2013. Over 2013, what 
percentage of active duty Army soldiers were prescribe some 
form of opioid?
    General Coots. Senator, I do not have that exact number.
    Senator Blumenthal. What is the last year for which you 
have a number?
    General Coots. Sir, actually I do. It looks like about 24 
percent or so, about 24 percent in 2013. So, down from 26 
percent in 2011.
    Senator Blumenthal. 26 percent in 2011 to 2013, 24 percent?
    General Coots. Yes, Senator.
    Senator Blumenthal. So, it is a pretty small difference.
    General Coots. It is a small difference but I think it 
still represents a big cultural change and a move ahead because 
over the war years you saw a steady increase in it and the war 
is not yet over. We are still getting casualties although 
fewer; but over those last few years, we have been able to use 
these alternative modalities to include battlefield 
acupuncture. We use intranasal ketamine on the battlefield now 
which decreases the amount of morphine that you have to use.
    So, I think all of that is contributing as well in those 
complex casualties, and then translate that to our primary care 
clinics and our interdisciplinary pain management centers where 
we are implementing these alternative medications. I think all 
of that has been contributing to it.
    So, we are right at the beginning of this cultural shift 
and this cultural change.
    Senator Blumenthal. Let me just make sure that I understand 
that number. That is total active duty soldiers.
    General Coots. That is total active duty.
    Senator Blumenthal. 26 percent were prescribed some form of 
opioid in 2011 and 24 percent in 2013. That is not injured 
soldiers. It is all soldiers.
    General Coots. That is all soldiers. This is all soldiers 
sailors, airmen, and Marines. That is all DOD.
    Senator Blumenthal. OK. Let me ask you. You mentioned the 
warm handoff from active duty service to separation and VA 
treatment. As you probably know, many of us on this Committee 
have been concerned about the lack of interoperability of the 
Army medical records with the VA records in terms of the 
electronic medical record systems that each has.
    Do you see an effect of the lack of complete compatibility? 
I do not know what exactly the technical term would be, but I 
know that everybody is talking about trying to make it work 
better but still do not have an interoperable system.
    Do you see an effect of that?
    General Coots. Actually, no, Senator. We are very 
compatible and very interoperable when it goes to that. There 
may be narrow pipelines between the two electronic health 
records but it still allows us to transition and transfer that 
critical information on complex patients and patients on----
    Senator Blumenthal. Is there an automatic re-evaluation 
when a soldier or an airman or Marine, or sailor goes from 
active duty to veteran status; re-evaluation of the 
prescription opioids?
    In other words, does somebody say, well, you have been 
getting this medication or that, let us have a look here. Maybe 
we need to do something different.
    General Coots. To my understanding, there is an intake. 
Anytime you do a handoff or handover of a servicemember's care 
into the veterans' system, there is going to be an intake 
process.
    We transition all of that information from that one lead 
coordinator to the next. But certainly when they get in and 
they have a new provider, a new team who is taking over, there 
is a re-evaluation of everything that has happened in that 
servicemember's medical history now than they have become a 
veteran.
    That does not necessarily mean there is a change in 
therapeutic approach or a change in modalities but it certainly 
could mean that.
    Senator Blumenthal. It could mean it for an individual 
case.
    Let me ask Secretary Petzel whether he has any 
observations.
    Dr. Petzel. Thank you, Senator Blumenthal.
    A comment on a couple of things. First of all, we have 
ready access to everything that is electronic in the DOD 
records. The interoperability part, we are working toward being 
sure that things mean the same in each kind of record. So, that 
is improving. It is definitely improving.
    Also the transition is improving with TAP, the Transition 
Assistance Program. We present to each one of the exiting 
servicemembers about what is available in DOD. People are often 
identified now in that program that need to have a warm 
handoff. We are seeing much more of the at-risk patients being 
handed off to VA in a warm fashion.
    Senator Blumenthal. Just so I understand, I use the term 
but what does that mean?
    Dr. Petzel. That means there is a specific call to a VA 
medical center, this patient, John Jones, is transiting into 
the VA health care system. This is who he is. Here is what it 
means. We need an appointment for him. That is a warm handoff.
    What happens when they come to the VA--not all of them do, 
by the way. We need to understand that unfortunately we do not 
see as many people as we would like to see. They are evaluated. 
Our perspective as an organization is that we want to use the 
least risky, effective way of managing a patient's pain.
    So that my hope would be and the expectation would be that 
their pain is evaluated. The medications that they are 
evaluated on, a plan is developed with that patient for the 
management of their pain that would again lead to the least 
risky, most effective way of managing their pain.
    Chairman Sanders. I want to thank all of our panelists. 
This Committee considers the issue of overmedication to be a 
serious national problem, a problem within the VA and a problem 
within the DOD. We appreciate your focusing on it and the good 
work you are doing. So, thank you all very much.
    At this time I want to introduce our second panel. First, I 
am pleased to welcome Dr. Janet Kahn, who is a member of the 
Department of Psychiatry at the University of Vermont and 
Senior Policy Adviser for the Consortium of Academic Health 
Centers for Integrative Medicine. That is a mouthful.
    Then we have Dr. Mark Edlund, who is the Senior Research 
Public Health Analyst in the Behavioral Health Epidemiology 
Program at RTI International.
    Thank you both very much for being with us.
    Dr. Kahn, let us begin with you.

 STATEMENT OF JANET KAHN, Ph.D., RESEARCH ASSISTANT PROFESSOR, 
  DEPARTMENT OF PSYCHIATRY, UNIVERSITY OF VERMONT AND SENIOR 
   POLICY ADVISOR, CONSORTIUM OF ACADEMIC HEALTH CENTERS FOR 
                      INTEGRATIVE MEDICINE

    Ms. Kahn. Chairman Sanders, Ranking Member Burr, Members of 
the Committee, I want to thank you for the honor of testifying 
before this distinguished body on what we all agree is a really 
critical issue, the issue of overmedication, particularly 
overuse of opioids for pain management.
    I have been asked to share my understanding of what 
integrative health care approaches could offer to people in 
pain and people treating them.
    So, by way of background, I am a medical sociologist and 
for the past 30 years my work has focused on issues of 
integrative health care. I am also a clinician. I am a massage 
therapist and instructor of meditation and somatic awareness 
training. So, in that capacity in the treatment room what I 
have spent the last 30 years doing is trying to understand how 
people can move from illness to wellness, from pain and ease, 
and how a nervous system that has gotten stuck in a flight or 
fight or freeze state can reset itself for optimal functioning.
    For the past 5 years, almost all of my work has been with 
veterans of OEF, OIF, and OND and their partners. I have seen 
them in my private practice; and with my research partner, 
William Collinge, we utilize a program called Mission 
Reconnect.
    This is a self-directed, home-use Web- and app-based 
program that offers instructions to help veterans and their 
partners learn various mind-body techniques that we know to 
support mental, physical, and relationship health.
    Preliminary research that was conducted with veterans of 
the Vermont and Oregon National Guard units showed 8 weeks of 
this program to be effective in decreasing pain, decreasing 
anxiety levels, and decreasing people scores on PTSD checklist 
measurements.
    We are now conducting a randomized clinical trial of 
Mission Reconnect in San Diego, Dallas, Fayetteville, North 
Carolina, and New York to understand the regional differences 
and to cover all branches of the military.
    The term ``integrative medicine'' has been used with 
various meanings, so, I want to be clear that when I speak of 
integrative health care, I use the term to refer to team-based, 
coordinated use of the most appropriate evidence-based 
interventions from across the full conventional, complementary, 
and alternative medicine spectrum, including preventive efforts 
and a particular focus on interventions that educate and engage 
the patient and his or her family members in their own care 
and, therefore, hopefully leaving them with skills for a 
lifetime.
    I think we all know the relevant reports from the Army Pain 
Management Task Force and the IOM, and I would like to echo 
those reports in calling for a comprehensive change not only in 
how we treat pain but literally how we think about pain so that 
it can guide the treatment beginning with understanding that we 
do not actually treat pain, we treat people in all their 
complexity, and pain is part of what they bring to the picture.
    So many of the men and women returning from these wars have 
multiple wounds. They have injuries to their bodies, to their 
brains, to their hearts, to their minds, to their spirits, to 
their relationships; and we need to find a way to deal with 
that complexity as we treat them because they need more than 
just having their symptoms quieted. They actually need help 
learning to heal and to lead fulfilling lives in the many 
decades, being young, that they have ahead of them.
    Our current approach to pain management can too easily lead 
to prescribing a drug for each identified problem and that in 
turn, as we know, can lead to a poly pharmacy problem that we 
may not have the capacity to actually manage.
    These veterans have already been asked to carry and 
maneuver with more weight in their packs than their bodies were 
designed for. They have been exposed to more stress than their 
nervous systems can manage as we see absolutely every day. So, 
over medicating them is no solution and no gift.
    There are evidence-based, non-pharmaceutical ways to 
address pain. In this kind of complexity, I suggest that we 
reorient toward a positive vision of health and wellness for 
our veterans; try to come up under them.
    We know that lack of sleep, emotional stress, inability to 
take a deep breath, these things exacerbate pain. They 
literally make pain hurt more. They change the experience of 
it.
    So, addressing the building blocks of wellness can reduce 
the need for pain medication, and research clearly indicates 
that massage, acupuncture, yoga, and other mind-body therapies 
can significantly enhance sleep quality as well as duration, 
can help the nervous system rest down and thus reduce the 
experience of physical and emotional pain and alter the 
treatment needs for it.
    Educational interventions that include family members or 
groups of veterans can impart needed skills at the same time 
that they build community; and loss of community is an 
important element of a veteran's pain.
    So, on top of all that they have already offered this 
country, veterans are offering us, I believe, the opportunity 
to embrace a wellness approach to the care of people who have 
incurred complex trauma, to kick our pharmaceuticals-only 
habit, come up with something more complex and interactive, and 
learn to collaborate across disciplines on their behalf. We 
should recognize this as one more gift they are giving us and 
move toward it quickly.
    [The prepared statement of Ms. Kahn follows:]
     Testimony of Janet Kahn, Ph.D., Research Assistant Professor, 
   Department of Psychiatry, University of Vermont and Senior Policy 
Advisor, Consortium of Academic Health Centers for Integrative Medicine

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]




    Chairman Sanders. Thank you very much, Dr. Kahn.
    Dr. Edlund.

 STATEMENT OF MARK EDLUND, M.D., Ph.D., SENIOR RESEARCH PUBLIC 
  HEALTH ANALYST, BEHAVIORAL HEALTH EPIDEMIOLOGY PROGRAM, RTI 
                         INTERNATIONAL

    Dr. Edlund. Good morning. Thank you for inviting me. My 
name is Mark Edlund, and I am a health services researcher at 
RTI International and a practicing psychiatrist.
    For the past 10 years my colleagues and I have researched 
patterns of opioid painkiller prescribing in Blue Cross/Blue 
Shield, Arkansas Medicaid, and more recently the VA.
    Our research involves analyzing administrative data and 
pharmacy records. Most recently, our research has focused on 
national patterns of opioid prescribing in the VA, supported by 
a grant from the National Institute of Drug Abuse.
    The VA data come from the years 2009 to 2011. My testimony 
today will provide initial findings from our NIDA-funded work. 
This work examined three aspects of opioid prescribing in the 
VA.
    One, rates of opioid prescribing in VA patients with 
chronic non-cancer pain. Two, factors associated with 
discontinuation of chronic opioid therapy. And, three, factors 
associated with heavy utilization of opioids among VA patients 
with chronic pain.
    Rates of opioid prescribing in VA patients with chronic 
pain. Many VA patients have chronic pain, most commonly back 
pain and arthritis. Our results suggest that, among VA patients 
with chronic non-cancer pain who are using VA services at least 
twice per year, a little over half receive at least one 
outpatient opioid prescription in that year.
    Although comparing rates of opioid use between health care 
systems can be imprecise, this rate is approximately the same 
rate as found in other health care systems and in other health 
care plans.
    VA patients with chronic pain who receive opioids have a 
median of about 120 days of use in a year, that is, they used 
opioids about one 1 of 3 days--the median individual. This is 
generally higher than in other health care systems.
    In this same VA cohort, the median daily opioid dose is 
modest, about 21 milligram morphine equivalents. So, morphine 
equivalents are the way we standardize all these different 
opioids, and 21 milligrams is fairly low. High would be thought 
of as, say, 120 to 200. So, the median dose is generally lower 
in the VA than in other health care systems.
    Of the VA chronic pain patients prescribed opioids, the 
percentage who receive high doses of opioids is relatively 
small, about 5 percent. This is also lower than in other health 
care systems. This is important because high dose is an 
important predictor of adverse outcomes.
    The opioid use of OEF/OIF VA patients has been the subject 
of scrutiny. We found that, among VA patients with chronic 
pain, OEF/OIF patients were less likely to be prescribed 
opioids as compared to other VA patients; and among VA patients 
with chronic pain who were prescribed opioids, OEF/OIF veterans 
were less likely to be heavy utilizers of opioids.
    Rates of opioid discontinuation. Among VA patients who 
received at least 90 days of VA opioids within a 180-day period 
in 2009, we looked at rates of discontinuation where 
discontinuation was defined as 6 months with no opioid 
prescription.
    We found that among these VA patients nearly 80 percent 
will receive years of opioid therapy. This is consistent with 
what we have found in analyses of other health care plans. 
While high daily doses is not common among VA patients, both 
high daily doses and use of long-acting opioids were strong 
predictors of opioid discontinuation, or excuse me, 
continuation.
    Individuals with substance abuse disorders and mental 
health disorders were more likely to discontinue opioids in the 
VA. This is important because these patients are those who are 
at increased risk for opioid abuse.
    Factors associated with heavy opioid utilization among VA 
patients. In analyses of data from other health systems show 
individuals with substance abuse disorders are at a high risk 
for heavy utilization of opioids.
    However, in an analysis of VA patients with chronic pain 
known to be using the VA at least twice in a fiscal year, 
individuals with substance abuse were less likely to be heavy 
utilizers of opiates.
    In summary, while comparing health care systems can be 
imprecise, we found, one, among chronic pain patients rates of 
any opioid use is approximately the same in the VA and non-VA 
systems.
    However, among chronic pain patients in VA who receive 
opiates, the number of days for which they received opioids in 
a given year is generally higher than in non-VA systems. 
However, median daily dose in the VA is lower than in other 
health care systems.
    Finally, it appears that the VA does a better job of 
screening out individuals with substance abuse and mental 
health disorders from heavy utilization of opioids which is 
also very important because those are the people who are most 
likely to go on to abuse.
    [The prepared statement of Dr. Edlund follows:]
  Prepared Statement of Mark J. Edlund, M.D., Ph.D., Senior Research 
  Public Health Analyst, Behavioral Health Epidemiology Program, RTI 
                             International
    Good morning, thank you for inviting me. My name is Mark Edlund. I 
am a health services researcher at RTI International, and a practicing 
psychiatrist. For the past 10 years my colleagues and I have researched 
patterns of opioid painkiller prescribing in different health care 
systems. Our research involves analyzing administrative data and 
pharmacy records. Most recently, our research has focused on national 
patterns of opioid prescribing in the VHA, supported by a grant from 
the National Institute of Drug Abuse (NIDA).
    My testimony today will provide initial findings from our NIDA-
funded work. This work examined three aspects of opioid prescribing in 
the VHA: rates of opioid prescribing in VHA patients with chronic 
noncancer pain; factors associated with discontinuation of chronic 
opioid therapy; and, factors associated with chronic opioid use among 
VHA patients.
    Our research used VHA administrative and pharmacy data from years 
2009 to 2011. We have thus far conducted three different analyses of 
this data. The results from those analyses were reported at the 
Addiction Health Services meetings held October, 2013 in Portland, 
Oregon and the American Academy of Pain Medicine meetings held March, 
2014 in Phoenix, Arizona.
    While some of the research methods were the same for all three 
studies, some methods varied in each study, as did the VHA patient 
sample.
                        methods for all analyses
Data Source
    We used data from three VHA Sources

     Pharmacy Benefits Management Service (PBM)
     VHA Corporate Data Warehouse
     OEF/OIF roster

    Opioid Use Variables. Data included all opioid prescriptions 
(including date, daily dose, and type of opioid), other than injectable 
opioids and opioid suppositories (due to lack of conversion factors). 
We recorded the total number of opioid prescription fills for each 
patient within the fiscal year and calculated the number of days 
supplied for each patient in the year, as recorded by the dispensing 
pharmacist. The mean dose in morphine equivalents per day supplied for 
each patient was calculated by summing the morphine equivalents for 
each prescription filled during the year, and dividing by the number of 
days supplied.
    Other Variables. We used International Classification of Diseases-
9th Revision (ICD-9) codes from VHA Corporate Data Warehouse to 
construct variables for mental health diagnoses and substance use 
disorders. Chronic non-cancer pain conditions were also identified 
through ICD-9 codes and grouped into five broad categories encompassing 
the most common chronic noncancer pain conditions. These groupings 
included neck pain, back pain, arthritis/joint pain, headache/migraine 
and neuropathic pain, which are common to VHA patients. Demographic 
information such as age, race, gender and marital status were also 
extracted from the VHA Corporate Data Warehouse.
    IRB Approval. All analyses were approved by the Institutional 
Review Boards of The Central Arkansas Veterans Healthcare System and 
the University of Arkansas for Medical Sciences. A data use agreement 
was executed with each data repository.
     analysis 1--patterns of opioid use for chronic noncancer pain
Study Sample
    The study sample consisted of VHA patients in years 2009 to 2011 
who met the following criteria. Inclusion Criteria: 1) chronic 
noncancer pain diagnosis, as defined by two clinical encounters for the 
same chronic noncancer pain condition (neck pain, back pain, arthritis, 
headache/migraine, or neuropathic pain) at least 30 days apart, but no 
more than 365 days apart, 2) Received at least one opioid prescription 
during the year of chronic noncancer pain diagnosis, 3) Age 18 or 
older. Exclusion Criteria: 1) Cancer diagnosis at any time in 2008-12 
other than non-melanoma skin cancer, 2) resident of VHA nursing home or 
living in VHA domiciliary, 3) enrolled in VHA hospice benefits, 4) 
incomplete opioid prescription data, or 5) a prescription for a 
parenteral, suppository, or trans mucosal opioid. These criteria allow 
us to focus on VHA patients likely receiving opioids for the treatment 
of chronic noncancer pain.
                    key results from first analyses
    Many VHA patients have chronic pain, with the most common sources 
being back pain and arthritis. Our results suggest that, among VHA 
patients with chronic noncancer pain who are using the VA at least 
twice per year, a little over half receive at least one outpatient 
opioid prescription in that year. VA patients with chronic pain who 
receive opioids have a median of 120 days of use in a year, or about 
one out of three days. In this same VHA cohort the median daily opioid 
dose is modest, about 21 milligram morphine equivalents. 21 milligram 
morphine equivalents is fairly low, equivalent to about 2 Vicodin 
tablets. In our analyses the percentage of VHA patients who received 
high doses of opioids was relatively small--about five percent. Among 
VHA patients with chronic noncancer pain, 44% of all opioids were used 
by just 5% of patients; 1% of patients accounted for 17% of all opioids 
utilized.
    The opioid use of OEF/OIF VHA patients has been the subject of 
scrutiny. We found that, among VHA patients with chronic noncancer 
pain, OEF/OIF patients were less likely to be prescribed opioids 
compared to non OEF/OIF VHA patients, and less likely to be heavy 
utilizers of opioids.
    Conclusions: About half of all VHA patients with chronic noncancer 
pain receive opioids, and among those who receive opioids, the median 
days of use is 120 days. The median daily dose is modest. Total opioid 
use is heavily concentrated among a relatively small proportion of the 
VHA population with chronic noncancer pain.
Second Analysis:
    Our second set of analyses focused on discontinuation from chronic 
opioid therapy.
        analysis 2--discontinuation from chronic opioid therapy
Study Sample
    The study sample consisted of all adult VHA patients receiving 90 
days or greater supply of non-parenteral opioids with less than a 30-
day gap in supply within a 180-day period between January 1, 2009 and 
December 31, 2011. We refer to individuals who met these inclusion 
criteria as receiving chronic opioid therapy. The index date was 
defined as the first day of this 90-day period. A minimum of two prior 
encounters in the year preceding the index date were required to 
document routine use of VHA care. The year preceding the index period 
was used to identify additional exclusionary criteria and relevant co-
variables. Veterans with an ICD-9 cancer diagnosis (with the exception 
of non-melanoma skin cancers) and administrative codes for VHA nursing 
home use, hospice or palliative care services in the 360 days before 
and after the index date were excluded. Additionally, veterans with 
incomplete opioid prescription data (unknown dosages or types) or 
enrollment in a methadone maintenance program or receiving 
buprenorphine at any time were excluded.
    Given high rates of interrupted or episodic use among chronic 
opioid users and to maintain consistency in definitions, 
discontinuation was defined as the first run-out day of a minimum 180-
day period with no opioid prescriptions. In order to distinguish 
clearly between disenrollment from VHA and opioid discontinuation, 
participants without any VHA services use in the 90 days after 
discontinuation were excluded.
    If any two prescriptions overlapped by greater than 20% or greater 
than ten days, the overlapping portions of the prescription were 
assumed to be taken concurrently and the overlapping days were only 
included once in the opioid days calculation. If the overlap was > 20% 
and > 10 days the second prescription was shifted and the overlapping 
days from both the first and second prescription were included in the 
opioid days calculation. A dichotomous variable for the presence of 
multiple opioids defined as two or more types of opioids that 
overlapped by more than 30 days in any 40-day period was created as a 
surrogate for potential opioid misuse.
    VHA service utilization during the period of chronic opioid therapy 
was calculated as the total number of mental health encounters, 
substance use encounters and all other VHA encounters abstracted from 
Current Procedural Terminology (CPT) codes in the 90 days post-index.
   key results from analysis 2--discontinuation from chronic opioid 
                                therapy
    We identified 814,311 VHA patients who met our criteria for chronic 
opioid therapy. After exclusions were applied, 550,548 (67.6% of 
chronic opioid users) were eligible for analysis and 542,843 were 
entered into the statistical models. (We excluded 7,705 (1.4%) of the 
sample due to missing data, primarily the absence of reliable rural/
urban coding). The sample was primarily male (93%), white (74%) and 
urban-dwelling (68%), with a mean age of 57.8 years and 52% were 
married. At one year after their index prescription date, only 7.5% of 
the sample had discontinued chronic opioid therapy.
    The majority of the sample suffered from at least one chronic 
noncancer pain condition (82.3%); just over a quarter of the sample had 
two chronic noncancer pain conditions (26.7%). Similarly, 62.3% of the 
sample had a mental health diagnosis, the most common being depressive 
disorder (29.7%). Only 14.5% of the sample had a substance use 
disorder, while 25.6% of the total sample used tobacco. The mean number 
of total clinical encounters in 90-days post-index was almost 9 (mean 
8.92, SD 11.01).
    The mean daily morphine equivalent dose was 40.7 mg (SD 61.67 mg) 
among the VHA patients in this analysis though the median was 26 mg and 
only 7% received greater than 100 mg daily morphine equivalent. Nearly 
all received short-acting opioids (97.1%). Only 12.3% received multiple 
concurrent opioid prescriptions, usually a long-acting plus a short-
acting opioid, and over half (57%) had received greater than 90 days 
total opioid supply in the year preceding their index date.
    We conducted analyses to examine factors associated with 
discontinuation from long-term opioid therapy. The maximum time 
available for follow-up was 1,279 days (3.5 years), and of those who 
discontinued (20%, N=110,460), the mean time to discontinuation was 530 
days (SD 298.15, median: 465). The majority of the sample continued use 
through the end of the follow-up period. Demographic characteristics 
associated with higher rates of discontinuation of long-term opioid 
therapy included being younger or older than VHA patients aged 50-65 
(0-30 years HR=1.52, 95% CI 1.47 to 1.57 and > 65 years HR=1.34, 95% CI 
1.32 to 1.36), non-married status (HR 1.06, 95% CI 1.05 to 1.08) and 
African American race (HR 1.04, 95% CI 1.02 to 1.06). Compared with VHA 
patients living in an isolated rural setting, those in an urban setting 
were significantly more likely to discontinue long-term opioid therapy 
(HR 1.08, 95% CI 1.05 to 1.10).
    VHA patients who were receiving higher average daily doses of 
opioids were less likely to discontinue chronic opioid therapy. Those 
taking long-acting opioid formulations had roughly 6% lower rates 
discontinuation of chronic opioid therapy compared with those taking 
short-acting opioid medications. (HR 0.94, 95% CI 0.90 to 0.98 VHA 
patients). Those receiving multiple opioid prescriptions concurrently 
had about a 20% lower rate of discontinuation compared with VHA 
patients receiving only one opioid medication (HR 0.80, 95% CI 0.78 to 
0.82). Finally, VHA patients with significant use of opioids in the 
year prior to the index date had almost a 30% lower rate of opioid 
discontinuations (HR 0.69, 95% CI 0.68 to 0.70). VHA patients who had 
multiple types of pain or who had greater level of medical comorbidity 
were more likely to continue chronic opioid therapy.
    For the cohort of VHA patients in this analysis, mental health 
diagnoses were associated with greater likelihood of discontinuation of 
chronic opioid therapy, with schizophrenia and bipolar diagnoses 
associated with nearly 20% greater hazard of discontinuation (HR 1.20, 
95% CI 1.16 to 1.25 for schizophrenia and HR 1.20, 95% CI 1.16 to 1.23 
for bipolar). Alcohol use disorder (HR 1.10, 95% CI 1.07 to 1.12), 
opioid use disorder (HR 1.09, 95% CI 1.06 to 1.13) and non-opioid use 
disorders (HR 1.22, 95% CI 1.19 to 1.25) were all significantly 
associated with higher rates of discontinuation. In contrast to other 
mental health and substance use predictors, tobacco use disorders were 
associated with higher rates of continued long-term opioid therapy 
(HR 0.96, 95% CI 0.94 to 0.97).
    Conclusions: Among VHA patients who had received at least 90 days 
of opioids within a 180 day period in 2009, nearly 80% went on to 
receive years of opioid therapy. This is similar in other health care 
plans. However, in other health care plans we studied, individuals who 
were at high risk for opioid abuse, namely those with substance use 
disorders and mental health disorders, were more likely to receive high 
dose opioids and less likely to discontinue opioids. We generally did 
not find this in the VHA. As noted above, VHA patients with mental 
health diagnoses, diagnosed disorders related to alcohol use as well as 
opioid and non-opioid substance use disorders were more likely to be 
discontinued from long-term opioid therapy. Thus, it appears that VHA 
does better than other health care systems previously studied in terms 
of discontinuing patients from chronic opioid therapy.
Third Analysis:
    Our third analysis examined factors associated with chronic opioid 
use among VHA patients who regularly used VHA care in FY 2011.
 analysis 3--chronic opioid use among all vha patients with or without 
                        chronic non cancer pain
Study Sample
    To be included in the cohort for the third analysis we identified 
all Veterans who had at least one outpatient opioid prescription in FY 
2011 using data from the VHA Pharmacy Benefits Management Service. 
Similar to our 2nd analysis we used secure mechanisms to link the data 
from the Pharmacy Benefits Management Service to that of the Corporate 
Data Warehouse to identify VHA patients who used VHA care at least 
twice in FY 2011. VHA patients with an ICD-9 cancer diagnosis (with the 
exception of non-melanoma skin cancers) and administrative codes for 
VHA nursing home use, hospice or palliative care services, had codes 
for methadone maintenance or were receiving buprenorphine were also 
excluded from the sample. In addition, VHA patients receiving 
outpatient opioid prescriptions for injectable opioids, opioid 
suppositories or trans mucosal opioid preparations were also excluded 
from the analysis. VHA patients were not required to have a chronic 
pain diagnosis to be included in this sample. Based on these inclusion 
and exclusion criteria, we identified a total of 1,127,955 VHA patients 
who were using opioid medications in FY 2011. Almost 52% (584,765) of 
VHA patients in this analysis were using opioids for 91 or more days 
during that fiscal year.
key results from analysis 3--chronic opioid use among all vha patients 
                 with or without chronic noncancer pain
    In unadjusted results, chronic opioid users were slightly older 
than non-chronic users (59 years vs 57 years), were more likely to be 
white (72.9% vs 65.9%), and were less likely to be OEF/OIF/OND Veterans 
(5.9% vs 11.1%).
    We used a logistic regression model to identify factors associated 
with chronic opioid use in this cohort in FY 2011 (adjusted results). 
In this cohort, opioid use was most common in VHA patients ages 56 to 
65 years; patients in other age groups were less likely to have chronic 
opioid use. The difference was most noticeable in the youngest age 
group. VHA patients ages 18-25 were almost 62% less likely than VHA 
patients ages 56-65 years to receive chronic opioid therapy (OR=0.38, 
95% CI=.36-.39). Non-white VHA patients were approximately 28% less 
likely than white VHA patients to receive opioid medications 
chronically (OR=.72, 95% CI=.71-.73). VHA patients in whom race was 
unknown were also less likely to receive chronic opioid medications 
although the difference was less pronounced with these patients being 
8% less likely to receive chronic opioid therapy compared with white 
patients (OR=.92, 95% CI=.90-.93). In this cohort women patients were 
22% less likely to receive chronic opioid therapy compared with male 
patients (OR=.78, 95% CI=.77-.79). VHA patients who were identified as 
OEF/OIF Veterans were 34% less likely to receiving chronic opioid 
therapy compared with non-OEF/OIF Veterans (OR=.66, 95% CI=.65-.67).
    In this cohort having PTSD or a depressive disorder was associated 
with receiving chronic opioid therapy. VHA patients in this cohort with 
a PTSD diagnosis were 16% more likely to receiving chronic opioid 
therapy compared with VHA patients without PTSD (OR=1.16, 95% CI=1.15-
1.18). VHA patients in this cohort with a diagnosis of a depressive 
disorder were 25% more likely to receive chronic opioid medications 
(OR=1.25, 95% CI=1.24-1.26).
    In this model, likelihood of chronic opioid use was most strongly 
associated with opioid dose, use of long-acting opioid medications and 
receiving multiple opioid medications concurrently. VHA patients in 
this cohort who were receiving 100MG morphine equivalent dose or more 
each day were 68% more likely to receive opioids chronically (OR=1.68, 
95% CI=1.60-1.76. VHA patients who were receiving long-acting opioid 
medications were almost four times as likely to receive opioids 
chronically compared to those receiving short-acting medications 
(OR=3.77, 95% CI=3.6-3.8) while those receiving multiple opioid 
medications concurrently were more than 30 times more likely to receive 
opioids chronically (OR=30.8, 95% CI=29.4-32.3).
    Conclusions: Of VHA patients who use opioids, about half use them 
chronically (at least 89 days per year). VHA patients who were non-
whites, OEF/OIF, or female were less likely to receive chronic opioid 
therapy. Individuals with mental health disorders were more likely to 
receive opioids chronically, but the magnitude of this effect was 
small. Higher opioid dose, use of multiple opioids concurrently and use 
of long-acting opioid medications were strongly associated with chronic 
opioid use.
                                caveats
    Our results should be interpreted with 4 factors in mind. First, we 
had access only to VHA records, and do not know about opioids VHA 
patients may be receiving outside the VHA system. Second, the 
definition of chronic pain is inherently subjective. In our first 
analysis we used a definition that is relatively strict. With less 
strict definitions, the percentage of VA chronic pain patients 
receiving opioids would likely be lower, as would the number of days of 
opioids used in a year. Third, the definition of high dose opioids is 
also subjective. We used a measure of high dose opioids that is on the 
low side. If we had used a measure that was higher, then our estimate 
of the percentage of VA patients with chronic pain who received high 
dose opioid therapy would have been lower. Fourth, although we reviewed 
records of all VHA patients in various years we included only specific 
patients in our analyses because we wanted to identify Veterans that 
were known to be using VHA care regularly.

    Thank you.

    Chairman Sanders. Dr. Edlund, thank you very much for your 
testimony.
    Let me start with Dr. Kahn and just ask you a pretty simple 
question. Let's say there is a veteran who is coming back from 
Iraq and Afghanistan dealing with pain issues, back pain or 
whatever it may be, he or she has difficulty sleeping, maybe 
the marriage is in trouble, they have difficulty holding on to 
a job.
    You said the issue here is not to deal with pain but to 
deal with the person. In the real world, somebody walks into 
your door with the issues I have described, the easy path is to 
medicate. Historically, we have done a lot of that. You have 
got pain; here are some drugs.
    You are proposing a different way. In English and maybe 
some concrete examples, what does that mean? What do you do 
with that individual who walked in your door?
    Ms. Kahn. So, I hope I made it clear that I am not 
suggesting an either/or approach.
    Chairman Sanders. No. We understand absolutely.
    Ms. Kahn. OK. And I want to state clearly that I am not a 
physician.
    Chairman Sanders. Right.
    Ms. Kahn. OK. So, that said, yes. I assume a physician 
would address issues of pain directly but at the same time 
because people's experience of pain and their capacity to 
handle and to cope with pain and manage whatever level of pain 
they are experiencing, is influenced by these other things like 
their general state of anxiety or whether or not they are sleep 
deprived and, therefore, on edge in a different way, we want to 
come up under them in terms of those elements of life at the 
same time as addressing the pain directly. That is what I am 
suggesting.
    Chairman Sanders. Give me some examples, if you can, of the 
effectiveness of the approach you are utilizing. Does it work? 
Do you have some examples of people who have walked in the door 
who have been able to get effective treatment, see real 
improvements in their lives with minimal use of heavy drugs?
    Ms. Kahn. I think I am actually not in a position to answer 
that yet because in my own practice of offering Mission 
Reconnect to people the first trial with that program was not 
done in a VA context or in a medical context, thus I did not 
have access to medical records to be able to assess changes in 
medication prescription or use.
    We have been approached by psychologists at the Tampa VA, 
and they are in the process of preparing a proposal to look at 
exactly that, to apply Mission Reconnect with other care for 
people who are both high PTSD and high pain.
    Chairman Sanders. OK. Dr. Edlund, do you have some thoughts 
on that?
    Dr. Edlund. I think that these strategies are 
underutilized. I think that they hold promise. I think that 
they are particularly attractive in that they are noninvasive 
and they do not involve medication.
    I think that ultimately they are going to be an important 
part of the puzzle and there is no one piece of the puzzle that 
is dominant. So, I agree that all of these elements need to be 
brought to the fore.
    Chairman Sanders. In your opinion, Dr. Edlund, has VA been 
aggressive in exploring these new approaches?
    Dr. Edlund. I would say that the VA has been more 
aggressive than the rest of the American health care system and 
that the level of aggressiveness has markedly increased in the 
last 2 or 3 years.
    Chairman Sanders. So, if you walked into a VA facility you 
would be more likely to have the option of looking at these 
approaches than in a private-sector hospital. Is that what you 
are saying?
    Dr. Edlund. Yes, almost certainly.
    Chairman Sanders. OK. Dr. Kahn, do you have anything to add 
to that?
    Ms. Kahn. Well, only that because in the non-governmental 
world, in the world of private insurance, most complementary 
and alternative medicine forms have not been and continue not 
to really be fully reimbursed. Then the patient is faced with a 
tougher choice if they are going to have to pay for it 
themselves in a private hospital than in the VA. So, I would 
imagine there would be greater use in the VA.
    Chairman Sanders. Well, that is an interesting observation. 
So, because insurance companies do not cover many of these 
complementary or alternative approaches, the private hospital 
is constrained about what kind of therapies it can offer.
    Ms. Kahn. Not necessarily what ones they offer but how they 
offer them. An increasing percentage of private hospitals do 
offer them, sometimes paid for philanthropically. Sometimes the 
hospital itself will pay and often it will be a fee that the 
patients themselves have to absorb.
    Chairman Sanders. OK. Thank you very much.
    Senator Burr.
    Senator Burr. Mr. Chairman, thank you.
    The one thing that I hope I will not fall prey to is trying 
to practice medicine from this side of the dias.
    Chairman Sanders. Give it a try.
    [Laughter.]
    Senator Burr. The truth is that the VA is a medical home 
and not everybody that prescribes in the private sector is 
necessarily that patient's medical home. They are referred to 
that pain specialist by their medical home and I think a 
medical home is more apt to look at all the conditions that 
surround an individual before they make a determination as to 
which course to follow, and I think that is why maybe in the 
private sector there are options.
    I think the Chairman's intent was to say that they are not 
all paid for by their insurance company where we have expanded 
it greatly in the VA.
    Dr. Kahn, I am fascinated to look at the studies once you 
have completed them in these multi-geographical areas with a 
variation of our active duty forces to see if we find 
variations between the Army and others. I look forward to that.
    But you testified that the VA needs to change from a 
problem-fixing mentality to a more rounded approach toward 
health care, and I think you alluded to the fact that this is a 
big organization. There are a lot of people, and that makes it 
challenging.
    What do you see as those challenges?
    Ms. Kahn. Well, first of all, any big boat takes a while to 
turn. So, size is simply one problem. I do not know exactly 
what the level of acceptance right now is among providers 
across the VA so that would have to be assessed.
    In general, I would say in the field of health care across 
all health care professions--complementary, alternative, 
conventional, I would say many of us are fairly arrogant about 
our own approach and not necessarily even well informed about 
other approaches.
    Senator Burr. What do you see as the biggest impediment for 
VA making this transition?
    Ms. Kahn. I do not see anything insurmountable. I think if 
the will is there it can absolutely be done. I think in general 
we have not seen large-scale use of integrative health care. It 
has been sort of an almost boutique form, but I think the 
single largest civilian health system that is integrating 
across the whole system is Allina Health, which is in Minnesota 
and Wisconsin. It is not the 150 medical centers and 1,500 
clinics that the VA has. It is 12 hospitals and 150 clinics. 
But it begins to show the scalability, and I think the VA could 
do it.
    Senator Burr. Dr. Edlund, tremendous research comes out of 
RTI, and we are grateful for that, and thank you for your work 
on this. Your testimony discusses several research studies you 
conducted regarding the patterns of opiate prescribing in VA 
facilities.
    Let me ask you, does RTI plan to conduct further research 
in that area?
    Dr. Edlund. I am hoping to submit another grant, yes; and 
we have submitted grants in the past that have not been funded. 
So, yes, it is an active area of research.
    Senator Burr. Can you describe for us what you see that 
next research project structured like, that you would submit 
that grant for?
    Dr. Edlund. Yes. The most recent grant that I have is 
actually not a VA grant. It is outside of the VA. Well, we will 
also be using VA physicians.
    We are looking at what goes into or how do physicians 
arrive at the decision to prescribe an opiate. Opiates are a 
two-edged sword, and the question is always how do you balance 
the risks and benefits.
    I am interested in understanding how they do that and what 
makes them decide along with the patient, OK, we are going to 
prescribe an opiate in this case or we are not going to 
prescribe an opiate in this case or we are going to escalate 
the opiate.
    So, these kind of fundamental decision-making processes 
that the physicians have to make along with the patient, we 
really do not understand at all and our next grant is to go in 
and try to better understand that.
    Senator Burr. Well, maybe, I can persuade Dr. Briggs for 
the Committee to answer that question that I believe she has 
probably looked at and it is a fascinating thing because I 
think we are making a big assumption that there is a tremendous 
amount of thought put into that determination.
    My observation would be opiates are prescribed a lot of 
times because that is what the patient came in and asked for, 
and doctors feel compelled to send them out with what, in fact, 
they requested. That may be part of our problem.
    I thank the Chair.
    Chairman Sanders. Thank you, Senator Burr.
    Senator Blumenthal.
    Senator Blumenthal. Thank you, Mr. Chairman.
    Dr. Edlund, this number may have been in your testimony but 
I have trouble seeing it highlighted there. Is there an average 
for the amount of time or the amount of drugs, opioids that are 
taken when they are prescribed?
    Dr. Edlund. I am sorry. I am not understanding. Is there 
what?
    Senator Blumenthal. Is there an average either period of 
time or amount of drugs over a period of time? In other words, 
someone who is prescribed an opioid takes it on average for 6 
months, 2 weeks, a year.
    Is there any data on how long the average prescription 
lasts?
    Dr. Edlund. Yes. Well, what we know is that--we 
differentiate between acute opiate use and chronic opiate use. 
So acute use would be you hurt your ankle and that is not what 
we are talking about.
    But with chronic use, what we know is that once an 
individual has been on chronic opioids for about 90 days, then 
most of those individuals will go on to use opioids for years. 
Really, you know, we cannot figure out and an average because 
at the end of 5 years, 75 percent of them will still be on 
opiates.
    Senator Blumenthal. Is there any data on whether the 
prescription for chronic users increases over time? In other 
words, does the amount of opioids prescribed have to increase 
to, in effect, take care of the same level of pain or for some 
other reason?
    Dr. Edlund. No. That is a very good question and that is 
poorly understood, meaning whether or not in what percentage of 
cases the opioid dose can be stable.
    Definitely in some cases you have to increase the dose over 
time because the patient develops a tolerance and that is the 
whole problem with opiate use is that, you know, it is a spiral 
that is always going upward. But we do not know how many people 
are in a spiral going upward and how many people are relatively 
stable.
    Senator Blumenthal. Is that not an important question?
    Dr. Edlund. Yes. There are a lot of fundamental important 
questions in opioids that have not been answered.
    Senator Blumenthal. I apologize for interrupting you but my 
time is limited; to follow up on Senator Burr's excellent 
question, it may well be that the patient comes in and says I 
need more, Doc.
    Dr. Edlund. It may very well be and I agree that a lot of 
times probably not a lot of thought is put into these 
decisions.
    Senator Blumenthal. And is there a way, for example, to 
have trip wires, for a lack of a better word? In other words, 
after 6 months there has to be a complete review by some 
independent medical professional or panel or some kind of 
authority to say, you know, there is a pattern here, increasing 
use over 6 months or, in other words, some kind of independent 
review.
    Dr. Edlund. Yes. Obviously that could be done easily, but 
to my knowledge it is fairly rarely done.
    Senator Blumenthal. And in your experience, to talk about 
Post Traumatic Stress--and I would ask this question of Dr. 
Kahn as well--Post Traumatic Stress, is that condition 
addressed therapeutically by opioid use or does opioid use 
address other conditions that, as Secretary Petzel said, may be 
found accompanied with Post Traumatic Stress, pain along with 
Post Traumatic Stress; is there an affect on the Post Traumatic 
Stress of using opioids either good or bad?
    Dr. Edlund. I am not familiar with that research. I do know 
that a lot of people with PTSD receive opioids, but I cannot 
speak to the finding.
    Senator Blumenthal. There is no research so far as you are 
aware----
    Dr. Edlund. Not that I am aware of.
    Senator Blumenthal [continuing]. Showing the effects on 
Post Traumatic Stress, minus of opioid use?
    Dr. Edlund. No, not that I am familiar with.
    Senator Blumenthal. Dr. Kahn, are you aware of any such 
research?
    Ms. Kahn. No, I am not.
    Senator Blumenthal. I would welcome--since I cannot ask the 
past panel whether they are aware of such research, if they 
are, please make me and perhaps the Committee aware of it.
    I thank you, Mr. Chairman. Just one footnote here which I 
have said before. I refer to Post Traumatic Stress as Post 
Traumatic Stress rather than Post Traumatic Stress Disorder, 
and I had said it to others who have testified here including 
Secretary Shinseki.
    You may agree or disagree but I think it is important to 
remove the stigma of Post Traumatic Stress by not referring to 
it as a disorder. I may be clinically and medically out in left 
field but so be it. Thank you.
    Thank you Mr. Chairman.
    Chairman Sanders. Senator Blumenthal, thank you very much 
and, Dr. Kahn, Dr. Edlund, thank you very much for helping us 
out on this very important issue.
    Ms. Kahn. Thank you.
    Chairman Sanders. And with that, the hearing is now 
adjourned.
    [Whereupon, at 11:53 a.m., the Committee was adjourned.]
                            A P P E N D I X

                              ----------                              


               Prepared Statement of The American Legion
          By the time Justin Minyard discovered the video of himself 
        stoned, drooling and unable to help his daughter unwrap her 
        Christmas presents, he was taking enough OxyContin, oxycodone 
        and Valium every day to deaden the pain of several terminally 
        ill cancer patients.
          ``Heroin addicts call it the nod,'' the former Special Forces 
        soldier says of his demeanor in that video. ``My head went 
        back. My eyes rolled back in my head. I started drooling on 
        myself. My daughter was asking why I wasn't helping her, why I 
        wasn't listening to her.''
          Seeing that video jolted Minyard out of a two-year opiate 
        stupor. He asked a Fort Bragg pain specialist to help him get 
        off the painkillers his primary care physician had prescribed. 
        ``I was extremely disappointed in myself,'' he says. ``I knew I 
        couldn't do that to my family again.''\1\
---------------------------------------------------------------------------
    \1\ Excerpt ``On the Edge'' The American Legion Magazine story by 
Ken Olsen, April 1, 2014.

    The preceding story is just one of many recent anecdotal accounts 
of veterans struggling with over-prescription of medications. In the 
best cases, the veteran in question has been able to pull themselves 
back from the brink, regroup, and work toward a different mode of care 
that doesn't have the same devastating effect on the veteran and their 
families. In the worst cases, veterans have died from accidental 
overdose, or attempted suicide in a medication-induced haze.
    In September 2013, CBS news reported the tragic tale of 35 year old 
Army SPC Scott McDonald, who tragically perished from the accidental 
overdose brought about by the cumulative effects of the lengthy list of 
medications he had been prescribed.\2\ The American Legion believes 
these risks increase the importance of exploring Complementary and 
Alternative Medicine (CAM) therapies \3\ that can reduce the 
overreliance on prescription drugs and help bring these veterans back 
from the brink of the abyss.
---------------------------------------------------------------------------
    \2\ http://www.cbsnews.com/news/veterans-dying-from-overmedication/
    \3\ Resolution #108: Request Congress Provide the Department of 
Veterans Affairs Adequate Funding for Medical and Prosthetic Research
---------------------------------------------------------------------------
    The American Legion has continued to be concerned with the 
unprecedented numbers of veterans returning from the wars in Iraq and 
Afghanistan suffering from TBI and PTSD, categorized as the ``signature 
wounds'' of these conflicts. The American Legion believes that all 
possibilities should be explored and considered in an attempt to 
finding treatments, therapies, and cures for TBI and PTSD to include 
alternative treatments and therapies, and they need to make them 
accessible to all veterans. If these alternative treatments and 
therapies are deemed effective they should be made available and 
integrated into the veterans' current health care model of care.
    As a result The American Legion established the TBI and PTSD 
Committee in 2010 comprised of American Legion Past National 
Commanders, Commission Chairmen, respected academic figures, and 
national American Legion staff. The Committee is focused on 
investigating existing science and procedures as well as alternative 
methods for treating TBI and PTSD that are not being employed by the 
Department of Defense (DOD) and VA for the purpose of determining if 
such alternative treatments are practical and efficacious.
    During a three year study the Committee met with leading 
authorities in the DOD, VA, academia, veterans, private sector mental 
health experts, and caregivers about treatments and therapies veterans 
have received or are currently receiving for their TBI and PTSD 
symptoms. Last year the Committee released their findings and 
recommendations in a report titled ``The War Within.'' ``The War 
Within'' report highlights these treatments and therapies and also 
identifies findings and recommendations to the DOD and VA.
               key highlights and findings of the report:
    Some of the critical findings of The War Within included:

     Most of the existing research for the last several years 
has only validated the current treatments that already exist--VA and 
DOD research is not pushing the boundaries of what can be done with new 
therapies, merely staying within an environment of self-confirmation 
bias.
     There seems to be a lack of fast track mechanisms within 
DOD and VA to employ innovative or novel therapies--a standardized 
approach to these therapies could help servicemembers and veterans gain 
access to care that could help them.
     While some VA medical centers (VAMCs) do offer 
complementary alternative medicine (CAM) therapies, they are not 
offered in a consistent or uniform manner across all 152 VAMCs 
nationwide--VA struggles with consistency and needs better guidance.

    In addition to those findings, the TBI and PTSD Committee made some 
recommendations for the way forward:

     Congress needs to provide oversight and funding to DOD and 
the VA for innovative TBI and PTSD research that is being used 
successfully in the private sector healthcare systems such as 
hyperbaric oxygen therapy, virtual reality exposure therapy, and non-
pharmacological treatments and therapies.\4\
---------------------------------------------------------------------------
    \4\ Resolution #108: Request Congress Provide the Department of 
Veterans Affairs Adequate Funding for Medical and Prosthetic Research
---------------------------------------------------------------------------
     Congress needs to increase DOD and the VA research and 
treatment budgets in order to improve the research, screening, 
diagnosis, and treatments for TBI and PTSD.
     DOD and VA need to accelerate their research efforts in 
order to effectively and efficiently diagnose and develop evidence-
based TBI and PTSD treatments.
                           continued efforts:
    The American Legion's efforts to assess the care and treatments 
available for veterans suffering from TBI and PTSD are not limited to 
the efforts of the TBI and PTSD Committee. In 2003, The American Legion 
established the System Worth Saving Task Force to conduct ongoing, on-
site evaluations of the Veterans Health Administration (VHA) medical 
system. Annually, System Worth Saving visits provide Legionnaires, 
Congress and the public with an in-depth, boots on the ground view of 
how veterans are receiving their healthcare across the country.
    Over the last several years, the System Worth Saving reports have 
examined the full spectrum of VHA care, but specifically have noted 
several things about how VHA delivers on complementary and alternative 
medicine (CAM) in their facilities.
    VA medical centers throughout the VA healthcare system are 
committed, dedicated, and compassionate about treating veterans with 
TBI. Many medical centers throughout the country have found successful 
complementary and alternative methods for the treatment of TBI and PTSD 
such as hiking, canoeing, nature trips, equine, and music therapy.\5\ 
While some systems like the El Paso VA Healthcare System offer several 
CAM solutions, such as yoga, guitar lesions, sleep hygiene and other 
practices, other locations such as the Pittsburgh VA and Roseburg VA 
Healthcare System are more limited, offering only acupuncture in 
Pittsburgh, and acupuncture for pain management through the fee basis 
program in Roseburg.\6\
---------------------------------------------------------------------------
    \5\ 2011 SWS--``Transition of Care from DOD to VA''
    \6\ 2014 SWS--``Past, Present and Future of VA Health Care''
---------------------------------------------------------------------------
    In addition to the ongoing System Worth Saving Task Force visits, 
The American Legion is taking the lead for veterans by aggressively 
pursuing the best possible treatment options for veterans on multiple 
fronts.
              hearing from veterans about their treatment:
    On February 3, 2014, The American Legion launched a TBI and PTSD 
survey online in order to evaluate the efficacy of the veterans' TBI 
and PTSD care, treatments, and therapies and to find out if they are 
receiving and benefiting from CAM treatment offered by the DOD and VA. 
The survey, conducted in coordination with the Data Recognition 
Corporation (DRC), Dr. Jeff Greenberg, Ph.D., and the Institute for the 
Advancement of Military and Veteran Healthcare, was to assist The 
American Legion to better understand the experiences of veterans who 
receive care throughout the VA healthcare system.
    William Detweiler, Past National Commander and Chairman of the TBI 
and PTSD Committee has stated about the survey, ``The American Legion 
is very concerned by the unprecedented number of veterans who suffer 
from these two conditions * * * We firmly believe that both VA and DOD 
need to act aggressively in adopting all effective treatments and 
cures, including alternatives being used in the private sector, and 
make them available to our veterans nationwide * * *. By completing 
this survey, veterans across America will have the opportunity to tell 
the true story of the types of care and treatments that they are 
actually receiving for PTSD and TBI. The survey will greatly help The 
American Legion in its efforts to advise the Administration, Congress, 
DOD, VA on the best possible care and treatments for these injuries.''
    The full survey results will be released and discussed in detail at 
the upcoming American Legion TBI and PTSD Symposium, June 2014, however 
two key data points emerged which bear special significance to this 
testimony.

     Medication appears to be the front line treatment reported 
by respondents.
     A sizable proportion of respondents reported prescriptions 
of up to 10 medications for PTSD/TBI across their treatment experience.

    Both of these data points should raise concerns about whether 
veterans are getting the right treatment for these signature wounds of 
the past decade's wars.
                               symposium:
    On June 24, 2014 in Washington, DC, The American Legion is hosting 
a TBI and PTSD Symposium entitled ``Advancing Care and Treatment for 
Veterans with TBI and PTSD.'' The symposium aims to discuss the 
findings and recommendations from the TBI and PTSD veteran's survey, 
and will hear directly from servicemembers, veterans, and caregivers on 
their TBI and PTSD experiences, treatments and care. The symposium will 
also help us determine how the Administration, Congress, DOD and VA are 
integrating complementary and alternative treatments and therapies into 
current models of veterans' health care.
                              conclusion:
    After a decade of war, America is still grappling with an evolving 
understanding of the nature of the wounds of warfare. Veterans must be 
reassured that the care they receive, whether serving on active duty in 
the military, or through the VA Healthcare system in their home town, 
is the best treatment available in the world. To combat the physical 
and psychological wounds of war, sometimes the old treatments are not 
going to be the most efficacious.
    Just as new understanding about the nature of these wounds emerges, 
so too must the new understanding about the best way to treat these 
wounds continue to adapt and evolve. Veterans are fortunate to have 
access to a healthcare system designed to treat their wounds, but that 
system must recognize that different treatments will have differing 
levels of effectiveness depending on the individual needs of the 
wounded veteran. There is no silver bullet. There is no single 
treatment guaranteed to cure all ailments. With a national policy that 
respects and encourages alternative therapies and cutting edge 
medicine, veterans have the best possible shot to get the treatment 
they need to continue being the productive backbone of society their 
discipline and training prepares them to be.
    Consider the following condensed version of one of the many veteran 
stories in The American Legion's The War Within:

            Tim Hecker joined the Army at 18 and soon decided to make a 
        career of it. He served 22 years in all, in and out of combat, 
        rising to the rank of master sergeant. In the summer of 1990, 
        he married his high school sweetheart, Tina, and the couple had 
        three children.
          Then Tim couldn't remember having married Tina. He couldn't 
        tell his sons apart. Their names escaped him. Injuries suffered 
        in two separate roadside-bomb explosions in a span of two 
        months in Iraq in early 2008 left him with a Traumatic Brain 
        Injury and severe post-traumatic stress. He was no longer the 
        man Tina had married.
          Frustrated with her husband's descent and the lack of 
        progress with traditional care, Tina went online and found 
        information about hyperbaric medicine. Following a phone call 
        and an initial interview, Tim was selected to be part of a 
        pilot study on the use of hyperbaric oxygen therapy (HBOT) for 
        Traumatic Brain Injury (TBI) and Posttraumatic Stress Disorder 
        (PTSD). He claims the treatments have given him back most of 
        his pre-injury life.
          ``By the fourth treatment, I started feeling like a new 
        person,'' he says at his home in West Edmeston, N.Y. ``I was 
        more aware. I could see things. The deeper I got into the 
        treatments, my cognition started to come back--my motor skills 
        and my balance. My vision started to improve. The biggest 
        benefit was my emotional control.''
          ``We're talking a 180-degree turn around,'' Tina says. 
        ``There are days when he's almost back to normal with his 
        personality.''\7\
---------------------------------------------------------------------------
    \7\ http://www.legion.org/publications/217301/war-within-treatment-
traumatic-brain-injury-and-post-traumatic-stress-disorder

    Ultimately, that is why it's so important to ensure VA solves the 
over medication puzzle. The veterans have already returned home from 
war. This is about helping the veterans to finally return home to their 
families.
    The American Legion looks forward to working with the Committee, as 
well as VA, to find solutions that work for America's veterans. For 
additional information regarding this testimony, please contact Mr. Ian 
de Planque at The American Legion's Legislative Division, (202) 861-
2700 or [email protected].
                                 ______
                                 
    Prepared Statement of Joy J. Ilem, Deputy National Legislative 
                  Director, Disabled American Veterans
    Chairman Sanders, Ranking Member Burr and Members of the Committee: 
DAV (Disabled American Veterans), an organization of 1.2 million 
wartime veterans who were wounded, injured or made ill due to their 
military service, appreciates this opportunity to offer testimony for 
the record of your hearing to examine overmedication and its problems 
and solutions in the Department of Veterans Affairs (VA).
    Less than a month ago, VA formally directed its 21 Veterans 
Integrated Service Networks (VISN) to launch a new and intensive opioid 
safety initiative. The stated goals are to reduce harm to veterans from 
unsafe medications and dosages, but to adequately control veterans' 
pain. While DAV offers no opposition to this initiative, our experience 
in recent years in several local instances with VA physicians who 
decided to abruptly discontinue prescribed opioids for our members 
without offering them alternatives does not lend confidence that this 
initiative will be carried out with sensitivity to the needs of 
veterans to tolerably manage their pain in absence of such drugs. Some 
of our members who contacted DAV had been prescribed these drugs for 
decades, and were tolerating their pain well, but were offered little 
to no alternatives when VA physicians decided to abruptly end such 
prescribing. In situations such as these, we are concerned that these 
veterans will turn to alcohol or illicit drugs in search of pain 
relief, or will be left to needlessly suffer.
    As we understand it, VA's opioid safety initiative contains nine 
goals. The initial goals (to be accomplished within six months, 
according to the directive) would establish systems to educate VA 
prescribers about safely and effectively prescribing opioids; increase 
the usage of urinalysis to detect presence of opioids in veterans' 
urine; provide VA prescribers potential access to state prescription 
databases to identify veterans who are in receipt of opioids from 
private prescribers; and establish ``tapering programs'' for certain 
veterans using opioids along with other drugs.
    The second set of VA goals, to be achieved over the next nine 
months, includes central development of a ``risk stratification 
toolkit'' to be deployed locally in VA facilities to enable physicians 
to assess veterans using opioids who should not be treated with them, 
or identify those who can be given reduced doses at a safer level. 
Another goal calls for each VISN to implement a uniform tapering 
program for certain ``high-risk'' opioids, with an overall objective of 
VA's achieving a 75 percent reduction in the use of certain opioids by 
not later than December 15, 2014.
    The third set of VA goals, to be achieved over a year or possibly 
longer, requires all VA facilities to identify veterans who are 
prescribed opioids above a stated dosage ceiling (200 milligrams of 
morphine equivalents per day). VA Central Office will collate this data 
and provide it to VISNs and facilities, which will be required to 
conduct appropriateness reviews with prescribers who are identified as 
providing veterans dosages higher than the dosage ceiling. Another goal 
is for all VA facilities to provide at least two unspecified 
complementary and alternative medicine (CAM) modalities in the 
treatment of chronic pain. These modalities are to be put in place by 
March 15, 2015.
    The last goal is to establish a mental health component within the 
Patient Aligned Care Team approach to delivering VA care to veterans 
with a history of prescribed opioid use, focusing on establishing a 
three-facility trial of deploying ``interdisciplinary medication risk 
management teams,'' to identify ``strong practices that can be 
operationalized across the VHA Healthcare System,'' to achieve further 
reductions in the use of prescribed opioids.
    The above description of VA's initiative is oversimplified and 
summarized for the Committee's use, but constitutes our understanding 
of its purpose based on our review of the directive and information we 
have received from VA practitioners who remain concerned about this new 
program's effectiveness and its impact on veterans in pain. To our 
knowledge neither DAV nor the remainder of the veterans service 
organization community have had a comprehensive briefing by VA on this 
new program, its purpose and justification, and how it will be 
implemented and monitored. It is also our understanding that, although 
already issued to VISNs and facilities, the directive is being 
reconsidered based on numerous concerns that have arisen since, and may 
be amended.
    While we have not received a national resolution from our 
membership on the topic of opioid reduction in VA health care, as 
indicated above, many of our members who were wounded, injured or made 
ill due to military service during wartime suffer from chronic pain 
from numerous causes other than malignancy (the only stated exception 
to this initiative), and presumably will be targeted by this new 
policy. The directive suggests that the use of CAM combined with 
integration of a specialized, and as yet untested, new mental health 
treatment model can substitute for existing prescribing practices by VA 
physicians who are dealing over time in primary and specialty care with 
veterans suffering from chronic pain and chronic pain syndrome.
    In a confounding countertrend, the Veterans Benefits Administration 
recently announced in the Federal Register that it has determined 
justification is sufficient to award service-connected ratings to 
veterans suffering from chronic pain and chronic pain syndrome, as 
discrete disabilities. DAV fully supports this broader authority to 
recognize that chronic pain is real, damaging and even debilitating. 
Also, this decision on rating veterans with chronic pain would suggest 
that chronic pain is a significant disabling condition from the vantage 
point of the VA division that awards disability compensation, whereas 
based on this new opioid reduction directive, another division of VA 
may see it quite differently.
    DAV is also concerned about VA's potential participation in state 
drug monitoring programs. Many of these activities were stimulated by 
law enforcement, not public health authorities, in a search for illicit 
prescribing practices by private physicians, and trafficking in 
controlled substances by people who defraud physicians. While we 
appreciate VA's legitimate interest in protecting against abuse and 
overuse of opioids, we are concerned about potential unintended 
consequences of VA's approach to these state monitoring programs and 
recommend close oversight by the Committee to ensure its purposes are 
limited to the health and safety of veterans and of their health care.
    DAV would never advocate for broad use of narcotics as a first 
line, or only line, of treatment for wounded, injured and ill veterans 
with chronic pain or chronic pain syndrome; however, the intent of VA's 
new initiative seems dedicated first to a drastic reduction in the use 
of painkiller drugs over other purposes, and may not keep uppermost the 
needs of veterans who suffer from chronic pain as a clinically 
legitimate treatment population.
    DAV strongly supports bringing significant CAM treatments into VA 
health care, particularly for younger veterans who do not want 
traditional health care, prescription medications or typical mental 
health treatments; however, if VA intends to use CAM as a substitute 
for, or replacement of, legally prescribed opioid medications in a 
known and older population, we urge VA to ensure the effects of 
shifting veterans away from these medications is closely followed in 
clinical care, lest these veterans resort to the abuse of alcohol or 
other drugs to compensate for the loss of painkillers that actually 
work for them. Additionally, VA facilities' selection of CAM models may 
not have the desired effect intended by this directive. For example, a 
study in the Journal of the American Medical Association (``Acupuncture 
for the Treatment of Cocaine Addiction: A Randomized Controlled 
Trial,'' January 27, 2010) that followed treatment of a large group of 
cocaine users diverted to acupuncture therapy as a substitute did not 
demonstrate effectiveness in reducing the use of cocaine in that 
population. In fact, the study ``does not support the use of 
acupuncture as a stand-alone treatment for cocaine addiction or in 
contexts in which patients receive only minimal concurrent psychosocial 
treatment.'' Numerous other published studies replicate this finding on 
acupuncture, and are reported on VA's Health Services Research and 
Development web page, http://www.hsrd.research.va.gov/publications/esp/
acupuncture.cfm. In our view, VA health care officials should carefully 
study the efficacy of CAM modalities as exchanges for prescribed 
opioids for pain to ensure they can accomplish the results intended, 
and that CAM modalities selected by facilities are efficacious for 
these purposes, are evidence-based, and are accompanied by appropriate 
other treatment resources.
    Mr. Chairman, perhaps most important to the purposes of this 
hearing, DAV is concerned that the required rapid implementation of 
this new directive will not be standardized and uniform across the vast 
VA system. In fact, the directive itself allows for local deviations 
and modifications, by ``providing opportunity for customization to meet 
local needs.'' The alternative approaches that are offered in the 
directive are vague, and may lead to wide variations, or only limited 
local implementation. In DAV's view, the directive should mandate 
interdisciplinary pain management teams be established at each 
facility, and ensure these teams are functional, before launching such 
an aggressive tapering program. The structure and function of such 
teams should be specified and mandatory. Without more specificity, a 
``pain management team'' may simply become a single provider designated 
in a facility whose primary (or imposed) clinical role would be to 
reduce the prescribing of opiates to veterans, without providing viable 
alternatives to address their pain.
    We believe any alternative treatments accompanying this plan should 
be specified and required in the directive. This availability should 
include psychological pain management treatments and other alternative 
treatments, including but not limited to specialized counseling, 
chiropractic care, and CAM approaches that are evidence-based. Even 
when some of these services are made ``available,'' a veteran with 
chronic pain may only be given a limited course of treatment, or be 
made to choose one or the other but not both to meet pain care needs. 
This would be an unfortunate and unsafe way to deal with opioid 
reduction due to its impact on the health of individual veterans. As an 
advocate for these veterans, especially those who were wounded, injured 
and ill due to military service, such an outcome would be unacceptable.
    During VA's initiative to implement a national formulary 15 years 
ago, many prescribers complained that they were disallowed from 
prescribing preferred, standard medications they had used for years in 
their practices because they were not a part of the then-new national 
formulary. In order for VA physicians to procure off-formulary drugs 
under the policy, VA established a national procedure in which the 
prescriber had to submit an explicit justification for use of a 
particular drug in an individual veteran's case, before a local or VISN 
VA pharmacy prescribing board, to gain approval of the deviation. This 
process at the time was seen as time consuming, a dampening influence, 
an interference of professional practice, and a difficult bureaucratic 
barrier. The formulary change accomplished the VA's goal of producing 
cost savings, but it came at the expense of many veterans who needed to 
adjust to new medications without warning and in some cases against the 
interests of their prescribing physicians. We hope and trust this new 
initiative will not carry similar consequences for the veterans it is 
going to affect.
    Finally, also about 15 years ago, it is helpful to recall that VA 
took the national and even international lead on establishing pain as 
the ``fifth vital sign.'' Hospitals and physician practices all over 
the world now use this concept in evaluating patients' pain level and 
developing interventions for pain as an important treatment goal on its 
own merit. Pain is the number one reason people, including wounded, 
injured and ill veterans, seek health care. DAV hopes VA will be able 
to carry out this new initiative to reduce opioid prescribing recalling 
its stewardship of pain management in western medicine, without rushing 
to judgment that veterans under VA care are atypically overprescribed 
narcotic medications. We understand from practitioners in VA facilities 
that, already, the pressure on, and monitoring of, providers to 
decrease their prescribing of opioids in pain management is leading to 
significant reductions in such prescribing, with no good alternatives 
available for affected veterans who are suffering from chronic pain. 
This is a troubling development, and we hope the Committee will 
thoroughly review this situation, not only during this hearing but on a 
recurring basis, to ensure that veterans experiencing pain remain VA's 
primary focus.

    Mr. Chairman and Members, this concludes DAV's statement. Again, 
DAV appreciates the indulgence of the Committee in permitting the 
submission of this testimony.
                                 ______
                                 
   Prepared Statement of Jacqueline A. Maffucci, Ph.D.,\1\ Research 
            Director, Iraq & Afghanistan Veterans of America
---------------------------------------------------------------------------
    \1\ Dr. Jackie Maffucci, IAVA's Research Director, holds a Ph.D. in 
neuroscience from the University of Texas at Austin. She previously 
worked with the Provost Marshall General and other senior leaders at 
the Armed Forces Services Corporation to develop, implement, and 
monitor research programs and opportunities to address the health and 
wellness needs of servicemembers.
---------------------------------------------------------------------------
    Chairman Sanders, Ranking Member Burr, and Distinguished Members of 
the Committee: On behalf of Iraq and Afghanistan Veterans of America 
(IAVA), I would like to extend our gratitude for being given the 
opportunity to share with you our views and recommendations regarding 
overmedication, an important issue that affects the lives of thousands 
of servicemembers and veterans.
    As the Nation's first and largest nonprofit, nonpartisan 
organization for veterans of the wars in Iraq and Afghanistan, IAVA's 
mission is critically important but simple--to improve the lives of 
Iraq and Afghanistan veterans and their families. With a steadily 
growing base of nearly 270,000 members and supporters, we aim to help 
create a society that honors and supports veterans of all generations.
    In partnership with other military and veteran service 
organizations, IAVA has worked tirelessly to see that veterans' and 
servicemembers' health concerns are comprehensively addressed by the 
Department of Veterans Affairs (VA) and by the Department of Defense 
(DOD). IAVA understands the necessity of integrated, effective, world-
class healthcare for servicemembers and veterans, and we will continue 
to advocate for the development of increased awareness, recognition and 
treatment of service-connected health concerns.
    A recent report from the Center for Investigative Reporting found 
that over the last 12 years, there has been a 270 percent increase in 
Veterans Health Administration (VHA) prescriptions for four powerful 
opiates.\2\ There has also been an increase in psychiatric medication 
prescriptions as well.\3\
---------------------------------------------------------------------------
    \2\ Glantz, A. (2013, September 28). VA's opiate overload feeds 
veterans' addictions, overdose death. Center for Investigative 
Reporting. Retrieved from http://cironline.org/node/5261
    \3\ Government Accountability Office. (2012, November 14). DOD and 
VA Healthcare: Medication Needs during Transitions May Not Be Managed 
for All Servicemembers. Retrieved from http://www.gao.gov/products/GAO-
13-26
---------------------------------------------------------------------------
    Given the last 12 years of conflict and the very physical and 
psychological demands on our troops, it is no surprise that veterans 
are seeking care at the VA for a multitude of needs. The use of 
medication to treat certain physical and mental conditions is a valid 
treatment option, but the VA must continue to develop a comprehensive 
and multidisciplinary approach to treatment.
    The need for comprehensive treatment is particularly prevalent in 
polytrauma cases, which are among the most complex medical cases to 
address. Pain often presents in consort with other conditions, such as 
depression, anxiety, PTSD, or TBI. Providers can be challenged to treat 
such polytrauma cases because of the challenge of managing multiple 
conditions. Some of these conditions may limit the drugs available to 
the patient, making treatment options limited.
    These issues constitute major challenges for providers. Certainly 
part of a treatment program for chronic pain or mental health issues 
may include strong medication, including opioids and psychiatric 
medications; but a schedule of treatment should not be limited to 
pharmaceutical treatment and should integrate a host of other proven 
therapies. This is why a stepped case management system can be very 
helpful. In this type of system, a primary care physician has the 
support of an integrated, multi-disciplinary team of providers to 
design and implement a comprehensive treatment plan for the patient.
    With approximately 22 veterans dying by suicide every day, and more 
attempting suicide,\4\ reducing instances of overmedication and 
limiting access to powerful prescription medications that can be used 
to intentionally overdose must be included in a comprehensive approach 
to addressing the issue. Particularly considering that overdosing is a 
common mechanism for suicide attempts, with over half of all non-fatal 
suicide events among veterans resulting from overdose or intentional 
poisoning.\5\
---------------------------------------------------------------------------
    \4\ Kemp, J. and Bossarte, R. (2012). Suicide Data Report 2012. 
Department of Veterans Affairs. Retrieved from http://www.va.gov/opa/
docs/suicide-data-report-2012-final.pdf
    \5\ Ibid.
---------------------------------------------------------------------------
    The VA's 2012 Suicide Data Report also showed that between 74-80 
percent of servicemembers and veterans sought care from a provider 
within four weeks of attempting suicide.\6\ This evidence shows the 
critical need for providers to not only provide access to timely mental 
health services, but also to ensure that the risk of overdose and 
overmedication are minimized through the use of state prescription 
monitoring programs and the creation of formulary take-back programs.
---------------------------------------------------------------------------
    \6\ Ibid.
---------------------------------------------------------------------------
    Given the challenging nature of understanding the medical and 
mental health needs of veterans, the VA and the DOD have made laudable 
initiatives to meet these needs. But the challenge remains to uniformly 
and effectively translate all of these efforts to practice. Too often 
we hear the stories of veterans who are prescribed what seems like an 
assortment of psychiatric medications and/or opioids with very little 
oversight or follow-up. On the flip side, there are also stories of 
veterans with enormous pain and doctors who won't consider their 
requests for stronger medication to manage the pain.
    One IAVA family member has expressed frustration and concern in 
regards to the VA's current opioid drug usage. Her husband, who was 
prescribed nine different medications to address a range of health 
issues related to pain, anxiety, and depression, tragically passed away 
from what was labeled an accidental overdose by the corner. Since then, 
his widow has been fighting for overmedication by the VA to be included 
on his death certificate.
    In a similar case highlighted by CBS, a veteran with 5 tours of 
duty in Iraq and Afghanistan received a treatment plan from the VA with 
a total of eight prescriptions. When he was prescribed a ninth drug by 
the VA he took the medicine as instructed. The next morning he was 
found by his wife. His death was classified as an accidental death due 
to overmedication. His widow plans to sue the VA for his death.
    It is not our job to second-guess the judgment of the doctors 
treating these patients, but it is our job to question the system that 
is providing overall care to our veterans and tracking this care. The 
VA has established practices and policies aimed at providing quality 
care to veterans, but it won't do our veterans any good if VHA cannot 
efficiently and effectively integrate these findings into their 
management practices and have a plan in place to continually improve 
upon accepted practice with evidence-based findings. While the VA has 
made great strides to recognize the need for comprehensive and 
multidisciplinary support, clearly there is still a lot of room for 
improvement in implementing these procedures.
    In part, some of the challenges may be in the inherent differences 
between the VA and DOD systems of care, whether it be in their 
available formularies, uniformity of record keeping and medical 
terminology used, or the interoperability, or lack thereof, of the 
medical record systems, care for our military and veteran population 
should be one integrated approach. A comprehensive treatment plan 
requires the VA and DOD have an integration of medical records such 
that receiving doctors are clear on the history of the patients that 
they intake. But beyond that, once the veteran is received into the VHA 
system, it's not just about putting out policies, clinical practice 
guidelines, and funding research. At the end of the day, the success 
will be seen in how those products are implemented into practice and 
how they are continually assessed for effectiveness. The key will be in 
education, integration, and assessment.
    Again, we appreciate the opportunity to offer our views on this 
important topic, and we look forward to continuing to work with each of 
you, your staff, and this Committee to improve the lives of veterans 
and their families.

    Thank you for your time and attention.
                                 ______
                                 
     A Report by Citizens Commission on Human Rights International
                               April 2014


[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                                  [all]