[Senate Hearing 115-634]
[From the U.S. Government Publishing Office]


                                                    S. Hrg. 115-634

         VA EFFORTS TO PREVENT AND COMBAT OPIOID OVERMEDICATION

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

                                HEARING

                                BEFORE A

                          SUBCOMMITTEE OF THE

            COMMITTEE ON APPROPRIATIONS UNITED STATES SENATE

                     ONE HUNDRED FIFTEENTH CONGRESS

                             FIRST SESSION

                               __________

                            SPECIAL HEARING

                   NOVEMBER 15, 2017--WASHINGTON, DC

                               __________

         Printed for the use of the Committee on Appropriations

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       Available via the World Wide Web: https://www.govinfo.gov

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                      COMMITTEE ON APPROPRIATIONS

                  THAD COCHRAN, Mississippi,  Chairman
MITCH McCONNELL, Kentucky            PATRICK J. LEAHY, Vermont, Vice 
RICHARD C. SHELBY, Alabama               Chairman
LAMAR ALEXANDER, Tennessee           PATTY MURRAY, Washington
SUSAN M. COLLINS, Maine              DIANNE FEINSTEIN, California
LISA MURKOWSKI, Alaska               RICHARD J. DURBIN, Illinois
LINDSEY GRAHAM, South Carolina       JACK REED, Rhode Island
ROY BLUNT, Missouri                  JON TESTER, Montana
JERRY MORAN, Kansas                  TOM UDALL, New Mexico
JOHN HOEVEN, North Dakota            JEANNE SHAHEEN, New Hampshire
JOHN BOOZMAN, Arkansas               JEFF MERKLEY, Oregon
SHELLEY MOORE CAPITO, West Virginia  CHRISTOPHER A. COONS, Delaware
JAMES LANKFORD, Oklahoma             BRIAN SCHATZ, Hawaii
STEVE DAINES, Montana                TAMMY BALDWIN, Wisconsin
JOHN KENNEDY, Louisiana              CHRIS MURPHY, Connecticut
MARCO RUBIO, Florida                 JOE MANCHIN, III, West Virginia
                                     CHRIS VAN HOLLEN, Maryland

                      Bruce Evans, Staff Director
              Charles E. Kieffer, Minority Staff Director
                                 
                                 
                                 ------                                

 Subcommittee on Military Construction, Veterans Affairs, and Related 
                                Agencies

                     JERRY MORAN, Kansas, Chairman
MITCH McCONNELL, Kentucky            BRIAN SCHATZ, Hawaii, Ranking 
LISA MURKOWSKI, Alaska                   Member
JOHN HOEVEN, North Dakota            JON TESTER, Montana
SUSAN M. COLLINS, Maine              PATTY MURRAY, Washington
JOHN BOOZMAN, Arkansas               JACK REED, Rhode Island
SHELLEY MOORE CAPITO, West Virginia  TOM UDALL, New Mexico
MARCO RUBIO, Florida                 TAMMY BALDWIN, Wisconsin
THAD COCHRAN, Mississippi (ex        CHRIS MURPHY, Connecticut
    officio)                         PATRICK J. LEAHY, Vermont
                                       (ex officio)

                           Professional Staff

                            Patrick Magnuson
                             D'Ann Lettieri
                            Jennifer Bastin

                       Christina Evans (Minority)
                      Chad C. Schulken (Minority)

                         Administrative Support

                              Carlos Elias
                           
                           
                           
                           C O N T E N T S

                              ----------                              
                                                                   Page


Opening Statement of Senator Jerry Moran.........................     1 
    Prepared Statement of Senator Jerry Moran....................     3 
Opening Statement of Senator Brian Schatz.......................      4
Opening Statement of Senator Patrick J. Leahy....................     4
Statement of Dr. Laurence Meyer, M.D., Chief Officer For Specialty Care,
  Veterans Health Administration; Accompanied by Dr. Friedhelm 
  Sandbrink, M.D., Acting National Program Director 
  for Pain Management............................................     6
      Prepared Statement of Dr. Laurence Meyer.....................   8
         Chronic Pain Across the Nation...........................    8
         VA's Progress in Pain Management.........................    8
         Alternative to Opioids...................................    9
         The Opioid Safety Initiative (OSI).......................   11
         State Prescription Drug Monitoring Programs..............   11
         VA's Opioid Education and Naloxone Distribution Program..   12
         Psychotropic Drug Safety Initiative......................   12
         CARA Implementation and Stop Pain........................   13
         Conclusion...............................................   13
Statement of Hon. Michael Missal, Inspector General, U.S. 
  Department of Veterens Affairs.................................    13
      Prepared Statement of Hon. Michael Missal....................  15
          Background...............................................  15
          OIG Report: Opioid Prescribing To High-risk Veterans 
          Receiving VA Purchased Care............................    16
          Findings.................................................  16
          Recommendations..........................................  17
          Conclusion...............................................  18
Statement of Mr. Marvin Simcakoski...............................    18
      Prepared Statement of Mr. Marvin Simcakoski..................  19
Implementation of Jason's Law....................................    21
Pain Management..................................................    23
Opioid Abuse and PTSD............................................    24
Opioid Safety Initiative.........................................    25
VA Patient Advocacy..............................................    27
Overprescription of Opioids......................................    28
VA Adaptive Sports Program.......................................    29
VA Environment of Care...........................................    29
Tracking Opioid Prescriptions....................................    30
Alternative and Complementary Therapies..........................    30
Alternative Therapies............................................    31
VA Chiropractic Care.............................................    33
VA Information Sharing With Community Providers..................    33
Opioids and the Native American Population.......................    34
VA Community Care Prescription Practices.........................    35
State Prescription Drug Monitoring Programs......................    36
Adverse Drug Interactions........................................    37
Alternative Therapies............................................    37
Pain Management Teams............................................    38
Medicinal Marijuana..............................................    38
VA Opioid Safety Training........................................    38
Department of Veterans Affairs Budget............................    40
VA Community Care Coordinators...................................    41
VA Electronic Medical Records....................................    41
Highly Addictive Prescription Drugs..............................    42
Non-VA Prescribing Practices.....................................    43
Opioid Prescribing Accountability................................    44
VA Care Coordination Teams.......................................    45
Additional Committee Question....................................    46
Question Submitted to Dr. Friedhelm Sandbrink....................    46
Question Submitted by Senator Susan M. Collins...................    46
  

 
         VA EFFORTS TO PREVENT AND COMBAT OPIOID OVERMEDICATION

                              ----------                              


                      WEDNESDAY, NOVEMBER 15, 2017

     Subcommittee on Military Construction,
             Veterans Affairs, and Related Agencies
                               Committee on Appropriations,
                                                    Washington, DC.
    The subcommittee met at 2:33 p.m. in room SD-124, Dirksen 
Senate Office Building, Hon. Jerry Moran (chairman) presiding.
    Present: Senators Moran, Murkowski, Hoeven, Collins, 
Boozman, Capito, Schatz, Leahy, Tester, Udall, Baldwin, and 
Murphy.


                opening statement of senator jerry moran


    Senator Moran. Good afternoon. The subcommittee will come 
to order. I'm very interested and pleased that we're having 
this hearing. Senator Baldwin as well as Senator Capito were 
instrumental in encouraging me, although Senator Baldwin went 
through everybody I know to tell me I should do this.
    [Laughter.]
    Senator Moran. I'm glad that I agree with all of them.
    It worked. And this is a timely topic, timely all the time, 
but especially now. And so we're pleased to have our eighth 
subcommittee hearing of this year, and we want to have a 
conversation and a discussion about pain management at the 
Department of Veterans Affairs, and particularly how to prevent 
the overprescription of opioids.
    In 2018, veterans were twice as likely--I'm sorry, 2011, 
veterans were twice as likely to die from accidental opioid 
overdose than non-veterans. In 2013, prescriptions for opioids 
increased by 270 percent over just 12 years, and the VA 
reported that more than 50 percent of veterans receiving care 
from the VA medical facilities were affected by chronic pain.
    According to more recent data, over 63 percent of veterans 
receiving chronic opioid treatment from the VA also have a 
mental health diagnosis.
    This subcommittee understands that the Department has been 
focused on creating and implementing better ways to monitor the 
prescription and usage of opioid medicines while embracing new 
and alternative pain management techniques to replace or in 
conjunction with this medication.
    In July of last year, the first major Federal addiction 
legislation in 40 years, the Comprehensive Addiction and 
Recovery Act (CARA) was signed into law to address the opioid 
epidemic in this country. CARA included a bill led by Senators 
Baldwin and Capito known as the Jason Simcakoski Memorial and 
Promise Act, or Jason's Law, named for Mr. Simcakoski's son. 
Mr. Simcakoski is a witness with us today.
    Thank you for joining us.
    In addition, the VA has its own opioid safety initiative to 
promote the safe and effective use of opioid therapy when 
clinically indicated. Today, we would like to hear from the 
Department about the progress that has been made in 
implementing Jason's Law and other initiatives and how this has 
changed prescribing behavior among clinicians at the VA as well 
as the rate of opioid use by veterans.
    Earlier this summer, the VA Office of Inspector General 
completed a report on non-VA providers prescribing opioids to 
veterans, and found that veterans utilizing care outside the VA 
may be put at a more significant risk due to conflicting 
prescribing guidelines among different clinical settings, and a 
lack of information sharing between inside and outside 
providers in order to accurately maintain health records of the 
veteran.
    According to the Inspector General (IG), non-VA providers, 
quote, ``do not consistently have access to critical health 
care information regarding the veterans they are treating,'' 
unquote. And the inability to monitor opioid prescriptions 
written by a non-VA clinician and filled by a non-VA pharmacy 
is a challenge.
    I understand that Senators Baldwin and Capito are once 
again at work to address this issue, and I support their 
effort. Today, I want the VA Office of Inspector General (OIG) 
to speak about these findings and how the Department can better 
serve their patients, particularly as more veterans are 
choosing to get their care outside the VA in community care.
    I wish to thank my colleagues Baldwin and Capito, as I've 
done, for requesting this hearing, and I look forward to 
working with them and the other members of this subcommittee 
and our colleagues to see that we make progress in this regard 
and that the Department of Veterans Affairs is doing its job as 
to the best of their abilities.
    As Members of Congress, we have no greater responsibility 
than responding to the need of our constituents, and I am 
grateful here to have Mr. Simcakoski present to speak directly 
to us about his experience with the VA. His courage is to be 
admired, and he is a significant advocate for his son, and his 
tireless commitment to his son's legacy are the reasons we're 
holding this hearing today.
    I look forward to hearing about Jason's life and your 
thoughts on how to make the outcomes different for other 
veterans in the future.
    In recent years, this committee has given the Department 
additional funding specifically for combating opioid abuse, 
supporting alternative treatments, and researching better 
methods of pain management. As I mentioned before, I wear two 
hats, as an appropriator charged with prioritizing the funding 
of the Department, as well as an authorizer with the ability to 
improve the laws that govern the VA process. I hope today's 
hearing facilitates a candid conversation about the 
improvements that the Department is making and needs to make 
and how Congress can support you with appropriate funding and 
needed changes in the law.
    [The statement follows:]

               Prepared Statement of Senator Jerry Moran
    The Subcommittee will come to order. Good afternoon. Welcome to our 
eighth subcommittee hearing of 2017. Thank you all for being here today 
to discuss better ways to address pain management in the Department of 
Veterans Affairs and prevent the over prescription of opioids.
    In 2011, veterans were twice as likely to die from accidental 
opioid overdoses as non-veterans. In 2013, prescriptions for opiates 
increased by 270 percent over just 12 years, and VA reported that more 
than 50 percent of veterans receiving care from VA medical facilities 
were affected by chronic pain. According to more recent data, over 63 
percent of veterans receiving chronic opioid treatment from VA also 
have a mental health diagnosis.
    This Subcommittee understands that the Department has been focused 
on creating and implementing better ways to monitor the prescribing and 
usage of opioid medicines while embracing new and alternative pain 
management techniques to be used in place of or in conjunction with 
medication. In July last year, the first major Federal addiction 
legislation in 40 years, the Comprehensive Addiction and Recovery Act 
(CARA), was signed into law to address the opioid epidemic in this 
country. CARA included a bill led by Senators Baldwin and Capito known 
as the Jason Simcakoski Memorial and Promise Act or Jason's law, named 
after Mr. Simcakoski's son. Mr. Simcakoski, thank you for being here 
with us today. In addition, VA has its own Opioid Safety Initiative to 
promote the safe and effective use of opioid therapy when clinically 
indicated.
    Today, we would like to hear from the Department about the progress 
you have made implementing Jason's law and other initiatives, and how 
this has changed prescribing behavior among clinicians at VA as well as 
the rates of opioid use by veterans.
    Earlier this summer, the VA Office of Inspector General completed a 
report on non-VA providers prescribing opioids to veterans and found 
that veterans utilizing care outside VA may be put at significant risk 
due to conflicting prescribing guidelines among the different clinical 
settings and the lack of information sharing between inside and outside 
providers in order to accurately maintain the health records of 
veterans. According to the Inspector General, non-VA providers ``do not 
consistently have access to critical healthcare information regarding 
the veterans they are treating,'' and the inability to monitor opioid 
prescriptions written by non-VA clinicians and filled by non-VA 
pharmacies is a challenge. I understand that Senators Baldwin and 
Capito are once again at work to address this issue, and I support 
their effort. Today, I want VA OIG to speak about these findings and 
how the Department can better serve their patients, particularly as 
more veterans are choosing to get their care out in the community 
closer to home.
    I wish to thank my colleagues Senators Baldwin and Capito for 
requesting we hold this hearing. You both have been champions 
uncovering issues within your local VA communities on this topic and 
also working with the Department to improve how it manages care. Thank 
you for commitment to making positive changes for our veterans.
    As Members of Congress, we have no greater responsibility than 
responding to the needs of our constituents. I am grateful today to 
have Mr. Marvin Simcakoski present to speak directly to us about his 
experience with VA. Mr. Simcakoski's courage to be an advocate for his 
son and his tireless commitment to his son's legacy are the reasons we 
are holding this hearing today. I look forward to hearing about Jason's 
life and your thoughts on how to make sure outcomes are different for 
other veterans in the future. Thank you again for being here.
    In recent years this Committee has given the Department additional 
funding specifically for combating opioid abuse, supporting alternative 
treatments, and researching better methods of pain management. As I've 
mentioned before, I wear two hats--as an appropriator charged with 
prioritizing the funding of the Department and as an authorizer with 
the ability to improve the laws that govern VA's processes. I hope 
today to facilitate a candid conversation about improvements the 
Department is making and needs to make, and how Congress can support 
you with appropriate funding and needed changes to the law.
    I'd like to introduce our panel:
    From the Department of Veterans Affairs: Dr. Laurence Meyer, M.D., 
Chief Officer for Specialty Care, and Dr. Friedhelm Sandbrink, M.D., 
Acting National Program Director for Pain Management; and also, the 
Honorable Michael L. Missal, Inspector General at the Department of 
Veterans Affairs; and Mr. Marvin Simcakoski from Stevens Point, 
Wisconsin. He is the father of the late Jason Simcakoski, the namesake 
of the Jason Simcakoski Memorial and Promise Act passed last year.

    Senator Moran. I now turn to my colleague and the ranking 
member of this subcommittee, Senator Schatz.

                   STATEMENT OF SENATOR BRIAN SCHATZ

    Senator Schatz. Thank you, Mr. Chairman.
    And thank you to our witnesses for appearing before the 
subcommittee today to discuss VA's efforts to address the 
opioid epidemic. I want to especially recognize Senators 
Baldwin and Capito for asking for this important hearing.
    There is no question that opioids are fueling a public 
health emergency. As the IG reported in July, overdose deaths 
involving prescription opioids have quadrupled since 1999, and 
this has hit our veterans especially hard. Behind these 
statistics are the heartbreaking stories of veterans like 
Marvin Simcakoski's son, Jason.
    Last year, Congress took an important step forward on this 
front when we passed the Comprehensive Addiction and Recovery 
Act. This bill included Title IX, which is named after Jason 
Simcakoski, to give the VA clear statutory authority to reduce 
reliance on opioid medications, particularly in treating 
chronic pain. This includes establishing safer prescribing and 
monitoring habits and expanding efforts in complementary and 
integrative health treatment. I look forward to hearing from 
Dr. Meyer and Dr. Sandbrink on the status of implementing 
Jason's Law as well as what more needs to be done.
    For example, I'm concerned that under Choice, we lose the 
ability to track all of the improvements made to address 
opioids in the VA because more than 35 percent of veterans are 
going outside of VA for care. We lose the transparency to see 
exactly how well our adjustments are working. Now, the VA is 
not alone here. This is a national public health crisis. And so 
we need more research to figure out how we can better help all 
patients and providers when it comes to chronic pain.
    Last year, I introduced the STOP Pain Act with Senator 
Hatch, which directed the National Institutes of Health (NIH) 
to intensify and coordinate research about chronic pain and to 
develop alternatives to opioids to treat chronic pain. This 
year, I'm working on legislation for the NIH-directed STOP Pain 
Initiative, which would put real funding and hundreds of 
millions of dollars behind these efforts.
    I know the VA also has new research and alternative 
treatment guidelines, and I would like to understand how these 
efforts can provide support for research into chronic pain and 
non-opioid alternatives to treat chronic pain.
    Thank you, Mr. Chairman.
    Senator Moran. Senator Schatz, thank you very much.
    We're pleased to be joined by the vice chairman of the full 
committee, Senator Leahy, and I recognize you if you have any 
opening comments.

                 STATEMENT OF SENATOR PATRICK J. LEAHY

    Senator Leahy. Thank you, Mr. Chairman. I appreciate that. 
You and I have discussed this before, and Senator Schatz and I 
have. There is--every state and every community in the country 
has been hit with the opioid epidemic. None of us can say we've 
escaped it. It's hitting sons and daughters and mothers, 
fathers, friends, coworkers. It is impacting our veterans, our 
servicemembers.
    We have over 16 years of war. We've asked members of our 
active reserve components to serve what's really an 
unprecedented number of deployments. We've left too many 
veterans broken and in pain. When we needed these brave men and 
women to return to battle, it was very easy just to prescribe 
opioids for pain management, but that's continuing when they 
return home. I think the military and the VA lean far too 
heavily on opioids to manage pain. It's an all too familiar 
story. Overprescribing opioid medications for chronic pain 
opens the door to addiction, overdose, suicide risk, and that 
devastates families and communities.
    In 2011, the VA said veterans are twice as likely to die 
from overdose than the U.S. civilian population. Just think of 
that, twice as often. We continue to prescribe opioids to 
veterans and active duty military at an alarming rate. Among 
veterans, the number of prescriptions written for opioid pain 
killers increased 77 percent between 2004 and 2012.
    Beginning in 2014, the VA, though, took the commonsense 
step of increasing patient education, alternative therapeutic 
approaches. Now, that resulted in 260,000 fewer patients 
receiving opioids this year, down from nearly 700,000 in 2012. 
But that means there are 400,000 more that are receiving--
400,000 others that are receiving them. I think this brings 
about a dangerous, highly addictive drug because they've been 
overprescribed, and we created a unique challenge for our 
nation's veterans and their families.
    Half of all returning veterans suffer chronic pain. More 
than 63 percent have a mental health diagnosis. They're more 
likely to suffer from chronic pain, the risk associated 
disability, psychological stress, and suicide.
    And, Mr. Simcakoski, you know too well the tragic 
consequences. All of us wish we could bring back your son for 
you, but nobody more than you do. You deserve better. Every 
veteran deserves better. Some progress has been made since we 
passed the Comprehensive Addiction Recovery Act last year, but 
we have to do a lot more.
    I have heard from several veterans in Vermont who are 
having difficulty accessing alternative treatments, 
acupuncture, chiropractic care, yoga, despite the efforts that 
the doctor had made, and they made it together, trying to 
settle on a non-opioid treatment. It shouldn't be easier to get 
a bottle of pills than it is to access the therapy you need 
right at home. That's not right. We have to do more. We have to 
do more to ensure both the VA and the private practices are 
communicating with each other so when a veteran makes use of a 
program like Choice, the history of pain management is taken 
into account.
    And I'm glad we're moving away from the conversation on 
opioid addiction, and we're moving to talking about--instead of 
talking about incarceration. I highlighted that during a Senate 
Judiciary Committee hearing back in 2008 when the committee, 
Republicans and Democrats, went to Vermont to see what we're 
doing.
    We're working together in the Senate Appropriations 
Committee. Mr. Chairman, I applaud you and Senator Schatz for 
this. To provide roughly $1.4 billion in fiscal year 2018 to 
address the opioid crisis. That's an increase of more than $137 
million above the President's request, $17 million above the 
House mark, and $41 million above fiscal year 2017. You know, 
this subcommittee alone provides $386 million to treat and 
prevent opioid dependency. We have a lot more to do.
    I hope we can reach a bipartisan budget deal, but, Mr. 
Chairman, I do want to applaud you and Senator Schatz for 
having this. And as vice chairman of the overall committee, I 
will work with both of you to help.
    Senator Moran. Thank you, Mr. Vice Chairman. We look 
forward to working with you, and we, too, hope that there is a 
budget agreement related to the caps in short order, as 
December 8th is just a few days away.
    Let me now introduce the panel. From the Department of 
Veterans Affairs is Dr. Laurence Meyer, Chief Officer for 
Specialty Care; and Dr. Friedhelm Sandbrink, Acting National 
Program Director for Pain Management; and also The Honorable 
Michael L. Missal, Inspector General at the Department of 
Veterans Affairs, welcome back; and Mr. Marvin Simcakoski, from 
Stevens Point, Wisconsin. He is the father of the late Jason 
Simcakoski, the namesake of the Jason Simcakoski Memorial and 
Promise Act passed last year.
    Welcome to all of you. And I now recognize Dr. Meyer.
STATEMENT OF DR. LAURENCE MEYER, M.D., CHIEF OFFICER 
            FOR SPECIALTY CARE
ACCOMPANIED BY DR. FRIEDHELM SANDBRINK, M.D., ACTING 
            NATIONAL PROGRAM DIRECTOR FOR PAIN MANAGEMENT
    Dr. Meyer. Good afternoon and thank you, Chairman Moran, 
Ranking Member Schatz, and members of the subcommittee. I thank 
you for the opportunity to testify about the use of opioids 
within the veteran community. I'm accompanied today by Dr. 
Friedhelm Sandbrink, Acting National Program Director for Pain 
Management.
    Our job at the VA is not only to care for veterans we 
serve, but ultimately to keep them free from harm while 
receiving care at our facilities. I want to express my sincere 
sympathy to any veterans and their families for whom we have 
failed to uphold this standard. We're constantly striving to 
make improvement in care, and we're happy to discuss the 
progress we've made over the last four years.
    Chronic pain management is challenging for veterans and 
clinicians. VA continues to focus efforts on identifying 
veteran-centric approaches that can be tailored to individual 
needs using medications as well as other modalities. Opioids 
can be effective treatment for some patients, but their use 
requires constant vigilance to minimize risks and adverse 
effects.
    The VA launched a system-wide Opioid Safety Initiative 
(OSI), in August 2013, and has seen significant improvement in 
the use of opioids since then. Changes in prescribing and 
consumption are occurring at a steady pace, and the OSI 
dashboard metrics indicate all trends are moving in the desired 
direction.
    A major challenge is patients already on long-term opioid 
therapy. Based on the VA/DoD opioid practice guidelines, opioid 
dosage adjustments in these patients should be individualized, 
and sudden opioid discontinuation should generally be avoided. 
This patient-centered process will give veterans time to adjust 
to new treatment options and to mitigate any patient 
dissatisfaction that may accompany these changes.
    The VA has also actively developed and disseminated new 
practice guidelines to avoid starting veterans on inappropriate 
opioids for pain and to address those who have substance use 
disorder. The VA has also trained all of our prescribers about 
safe opioid prescribing and the heroin crisis in response to a 
presidential memorandum.
    VA leadership has identified as its number one strategic 
goal to provide veterans personalized, proactive, patient-
driven health care. Integrated health care is being made 
available to all veterans. VA is expanding its efforts in 
complementary and integrative health treatments through the 
creation of programs in each veteran's integrated service 
network. We are eagerly awaiting the final appointment of the 
Creating Options for Veterans' Expedited Recovery (COVER) 
Commission members to allow this commission to begin its 
important work.
    Another risk management approach to support veterans and 
the public safety is VA participation in the state Prescription 
Drug Monitoring Programs (PDMPs). VA has implemented a 
regulatory change to enable VA prescribers to access 
information contained in these state databases. As of September 
2017, 48 states and the District of Columbia have PDMPs that 
are fully activated to receive VA data transmissions, and this 
is occurring. Information available through these programs will 
help both VA and non-VA providers prevent harm to patients that 
could occur if the provider were unaware the controlled 
substance medication had been prescribed elsewhere.
    In May 2014, a VA team developed and implemented the VA's 
Overdose Education and Naloxone Distribution program. As of 
October 30th, over 11,000 unique VA prescribers, stationed all 
across the VA health care systems, have prescribed over 112,000 
naloxone kits to veteran patients on long-term opioids or who 
have opioid use disorder. As a result of the Comprehensive 
Addiction and Recovery Act, or CARA, copays do not apply to 
naloxone kits or training. Also in accordance with CARA, the 
Office of Patient Advocacy was established on July 11th of this 
year, and reports directly to the Under Secretary of Health.
    VA is conducting reviews of clinicians' credentials during 
on- and off-boarding. These reviews explore potential risk 
areas related to any license violations which may impact their 
fitness for duty in or out of the VA.
    Finally, we announced the STOP PAIN effort in direct 
response to the President's Commission report. This effort 
brings together a comprehensive toolkit of best practices from 
CARA, Pain Management, OSI, and other programs.
    The VA continues to research alternatives and to implement 
programs to reduce the number of opioids prescribed and 
distributed.
    Thank you, Senator Capito and Senator Baldwin, for 
requesting this hearing so we can bring this important issue to 
light. My colleague and I are prepared to respond to any 
questions you or the subcommittee may have.
    Thank you.
    [The statement follows:]

             Prepared Statement of Dr. Laurence Meyer, M.D.
    Good afternoon, Chairman Moran, Ranking Member Schatz, and Members 
of the Subcommittee. Thank you for the opportunity to testify about the 
use of opioids within the Veteran community. I am accompanied today by 
Dr. Friedhelm Sandbrink, VA's Acting National Program Director for Pain 
Management.
    Our job at VA is not only to care for the Veterans who we serve, 
but also to keep them free from harm while receiving care at our 
facilities. Any adverse consequence that a Veteran might experience 
while in, or as a result of, our care is a tragedy. I want to express 
my sincere sympathy to any Veteran and their families for whom we have 
failed to uphold this standard. We will always have room for 
improvement in care, and we are taking immediate action upon any 
opportunity to do so.
    The president recently declared a public health emergency regarding 
the opioid crisis in our country, and VA is innovating and implementing 
new strategies rapidly to combat this national issue as it affects 
Veterans.
                     chronic pain across the nation
    Chronic pain affects the Veteran population, with almost 60 percent 
of returning Veterans who served in the Middle East and more than 50 
percent of older Veterans in the VA healthcare system living with some 
form of chronic pain. The treatment of Veterans' pain is often very 
complex. Many of our Veterans have survived severe battlefield 
injuries, some repeated, resulting in life-long moderate to severe pain 
related to damage to their musculoskeletal system and permanent nerve 
damage, which can impact their physical abilities, emotional health, 
and central nervous system. It is important to note as well that there 
are limited clinical trial data supporting the use of opioids for 
chronic paini. VHA is committed to reducing overreliance on opioid 
medicines especially in light of the severe negative consequences 
risked by many patients on opioids.
                    va's progress in pain management
    Chronic pain management is challenging for Veterans and clinicians. 
VA continues to focus on identifying Veteran-centric approaches that 
can be tailored to individual needs using medication and other 
modalities. Opioids can be an effective treatment for some patients, 
but their use requires constant vigilance to minimize risks and adverse 
effects. VA launched a system-wide Opioid Safety Initiative (OSI) in 
August 2013 and has seen significant improvement in the use of opioids. 
OSI has been designed to complement the Academic Detailing model. 
Academic Detailing is a proven method in changing clinicians' behavior 
when addressing a difficult medical problem in a population. Academic 
Detailing combines longitudinal monitoring of clinical practices, 
regular feedback to providers on performance, and education and 
training in safer and more effective pain management.
    VA has actively developed and disseminated new practice guidelines 
to avoid starting new Veterans on inappropriate opioids for pain and 
low back pain and to address those who have substance use disorder. 
These guidelines were released in 2017 and 2015 respectively and are 
available at:

https://www.healthquality.va.gov/guidelines/Pain/cot/,
https://www.healthquality.va.gov/guidelines/pain/lbp/index.asp, and
https://www.healthquality.va.gov/guidelines/MH/sud/.

    In March 2015, we launched the Opioid Therapy Risk Report (OTRR) 
tool, which provides detailed information on key risk factors of 
Veterans taking opioids to assist VA primary care clinicians with pain 
management treatment plans. We additionally added the Stratification 
Tool for Opioid Risk Mitigation (STORM), which uses predictive 
analytics to estimate risk of overdose or suicide in all patients on or 
considering opioid therapy and provides individually tailored 
recommendations for risk mitigation interventions and non-opioid pain 
management options. These tools are a core component of our 
reinvigorated focus on patient safety and effectiveness.
    VA's own data, as well as the peer-reviewed medical literature, 
suggest that VA is making progress relative to the rest of the Nation. 
In December 2014, an independent study by RTI International health 
services researcher, Mark Edlund, MD, PhD, and colleagues, supported by 
a grant from the National Institute on Drug Abuse, was published in the 
journal PAIN\1\. This study, using VHA pharmacy and administrative 
data, reviewed the duration of opioid therapy, the median daily dose of 
opioids, and the use of opioids in Veterans with substance use 
disorders and co-morbid chronic non-cancer pain. Dr. Edlund and his 
colleagues found that:
---------------------------------------------------------------------------
    \1\ Edlund MJ, Austen MA, Sullivan MD, Martin BC, Williams JS, 
Fortney JC, Hudson TJ.Patterns of opioid use for chronic noncancer pain 
in the Veterans Health Administration from 2009 to 2011. Pain. 2014 
Nov;155(11):2337-43.

  --About 50 percent of Veterans with chronic non-cancer pain in this 
        cohort received an opioid as part of treatment;
  --Half of all Veterans receiving opioids for chronic non-cancer pain, 
        are receiving them short-term (i.e., for less than 90 days per 
        year);
  --The daily opioid dose in VA is generally modest, with a median of 
        20 Morphine Equivalent Daily Dose (MEDD); and
  --The use of high-volume opioids (in terms of total annual dose) is 
        not increased in VA patients with substance use disorders as 
        has been found to be the case in non-VA patients.

    Although it is good to have this information, as confirmation of 
our efforts for several years, starting with the ``high alert'' opioid 
initiative in 2008 and including extensive educational and quality 
improvement initiatives, by no means is VA's work finished. By virtue 
of VA's central national role in medical student education and 
residency training of primary care physicians and providers, VA will be 
playing a major role in this transformation effort. We have already 
started with our robust education and training programs for primary 
care, such as Mini-Residency, Community of Practice calls, two Joint 
Incentive Fund training programs with the Department of Defense (DoD), 
and dissemination of the OSI Toolkit. The OSI Toolkit Task Force has 
published and promoted 16 evidenced-based documents and presentations 
to support the Academic Detailing model of the OSI. More information on 
the OSI Toolkit can be found here: https://www.va.gov/PAINMANAGEMENT/
Opioid_Safety_Initiative_OSI.asp.
                        alternatives to opioids
    VHA leadership has identified as its number one strategic goal ``to 
provide Veterans personalized, proactive, patient-driven healthcare.'' 
Integrated Health Care (IH), which includes Complementary and 
Integrative Medicine approaches, provides a framework that aligns with 
personalized, proactive, and patient-driven care. There is growing 
evidence for effectiveness of non-pharmacological approaches such as 
acupuncture, massage, and spinal manipulation as part of a 
comprehensive care plan for chronic pain, and psychological approaches 
such as Cognitive Behavioral Therapy for chronic pain are highly 
evidence-based. These are all being made available to Veterans.
    VA is undertaking efforts across the system to increase use of non-
opioid pain management strategies. These include:

  --Lowering dependency on opioid prescribing by incorporating a team 
        approach. VA has mandated that every facility set up an 
        interdisciplinary pain team, including clinicians with 
        expertise in addiction medicine, to help design and offer 
        effective treatment plans for complex patients.
  --Making use of a diverse array of non-opioid pain management options 
        for Veterans, helping to minimize need for opioid 
        prescriptions. For example, among patients receiving opioid 
        therapy in the last four quarters, 36 percent also received 
        physical therapy and 21 percent also received occupational 
        therapy in that year. Forty-seven percent of patients 
        prescribed opioids received psychosocial treatments in the last 
        year and 73 percent also received other nonopioid pain 
        pharmacotherapies. As VA implements a comprehensive approach to 
        pain management, fewer Veterans are prescribed opioid therapy, 
        and those that are receive a wide array of treatments, tailored 
        to their needs and preferences, with a strong focus on 
        rehabilitative and psychosocial interventions.
  --Implementing both universal and targeted risk mitigation strategies 
        for Veterans receiving opioid medication for pain to allow 
        prescribing in the safest way possible. Veterans on chronic 
        opioid therapy receive education on and discuss expected risks 
        and benefits with their providers, provide written 
        acknowledgement of their decision to receive chronic opioid 
        therapy, are regularly monitored with urine drug screening, and 
        VA checks their Prescription Drug Monitoring Program data. 
        Those at risk of overdose or suicide also receive overdose 
        education and naloxone prescriptions and develop personal 
        safety plans with their provider to ensure that they are 
        prepared in the case of crisis. VA's nationally available 
        decision support tools, OTRR and STORM help clinicians target, 
        apply, and monitor these risk mitigation interventions to 
        ensure that patients regularly receive these safety 
        interventions.
  --Educating Veterans and providing tools to better and more safely 
        manage their pain. VA has created a Patient/Family Management 
        toolkit in the Veterans' Health Library and updated resources 
        for pain management in My HealtheVet, the Veteran portal to 
        their health record. A pain management app called Pain Coach is 
        scheduled to be launched by the end of the year for use by 
        patients receiving pain management treatments.

    The VHA Office of Health Services Research and Development held a 
state-of-the-art (SOTA) conference titled ``Non-pharmacological 
Approaches to Chronic Musculoskeletal Pain Management'' in November 
2016. Workgroups reached consensus recommendations on clinical and 
research priorities for the following treatment strategies: 
psychological/behavioral therapies; exercise/movement therapies; manual 
therapies; and models for delivering multi-modal pain care. 
Participants in the SOTA conference identified non-pharmacological 
therapies with sufficient evidence to be implemented across the VHA 
system as part of pain care. These recommended psychological/behavioral 
therapies include cognitive behavioral therapy, acceptance and 
commitment therapy, and mindfulness based stress reduction. Exercise 
and movement therapies include Yoga and Tai Chi, and manual therapies 
include manipulation, acupuncture, and massage. The Integrative Health 
Coordinating Center within the Office of Patient Centered Care and 
Cultural Transformation leads the expansion of complementary and 
integrative health modalities.
    Veterans with chronic pain conditions, especially if severe and 
associated with medical and mental comorbidities, greatly benefit from 
a comprehensive approach that is founded on a biopsychosocial 
assessment and treatment, and thus addresses the needs of the whole 
person. Case management and coaching are effective tools within our 
pain treatment armamentarium to address the critical needs of Veterans 
with complex pain conditions. VHA offers Whole Health Coaching across 
VA and offers training to providers. The program is being rolled out 
system-wide. Whole Health Coaching addresses the psychological and 
social aspects of chronic pain by exploring the Veteran's reasons and 
motivation for pain management with an increased focus on functionality 
and doing ``what matters most'' to the Veteran. Whole Health providers 
partner with the Veteran to set personal goals for pain management that 
are individualized and motivational and then accompany the Veteran 
through the process of addressing and treating this pain.
    In 2011, VA's Healthcare Analysis and Information Group published a 
report on Complementary and Integrative Medicine in VA. At that time, 
89 percent of VHA facilities offered some form of Complementary and 
Integrative Medicine, however, there was extensive variability 
regarding the degree, level, and spectrum of services being offered in 
VHA. The top reasons for offering Complementary and Integrative 
Medicine included promotion of wellness, patient preferences, and 
adjunct to chronic disease management. The conditions most commonly 
treated with Complementary and Integrative Medicine include: stress 
management, anxiety disorders, post-traumatic stress disorder (PTSD), 
depression, and back pain.
    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 
local allocation of appropriated funds to contract for these services. 
Facilities are also able to use money in the General Post Fund, a trust 
fund administered by the Department, earmarked by the donor for this 
purpose to pay for these services.
    A monthly 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.
                   the opioid safety initiative (osi)
    OSI was chartered by the Under Secretary for Health in August 2012. 
OSI was piloted in several Veterans Integrated Service Networks (VISN). 
Based on the results of these pilot programs, OSI was implemented 
nationwide in August 2013. OSI's objective is to make the totality of 
opioid use visible at all levels in the organization. It 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 MEDD of opioids. Results of key clinical metrics 
measured by the OSI from Quarter 4, fiscal year (FY) 2012 (beginning in 
July 2012) to Quarter 4, fiscal year 2017 (ending in September 2017) 
are:

  --260,481 fewer patients receiving opioids (679,376 patients to 
        418,895 patients, a 38-percent reduction).
  --82,285 fewer patients receiving opioids and benzodiazepines 
        together (122,633 patients to 40,348 patients, a 67-percent 
        reduction).
  --192,742 fewer patients on long-term opioid therapy (438,329 to 
        245,587, a 44-percent reduction).
  --The overall dosage of opioids is decreasing in the VA system as 
        33,565 fewer patients (59,499 patients to 25,934 patients, a 
        56-percent reduction) are receiving greater than or equal to 
        100 Morphine Equivalent Daily Dose.
  --The percentage of patients on long-term opioid therapy with a Urine 
        Drug Screen (UDS) completed in the last year to help guide 
        treatment decision has increased from 37 percent to 88 percent 
        (51-percent increase). Notably, a longitudinal analysis of VA 
        data suggests that for every additional 1 percent of 
        opioidprescribed patients at a facility that receive monitoring 
        using urine drug screening, patient level risk of suicide- or 
        overdose-related healthcare events among those receiving opioid 
        therapy decreased by 1 percent.
  --The desired results of the Opioid Safety Initiative have been 
        achieved during a time that VA has seen an overall growth of 
        157,923 patients (3,959,852 patients to 4,117,775 patients, a 
        4-percent increase) that have utilized VA outpatient pharmacy 
        services.

    The changes in prescribing and consumption are occurring at a 
modest pace, and the OSI dashboard metrics indicate the overall trends 
are moving in the desired direction. In accordance with the VA/DoD 
Clinical Practice Guideline of Opioid Therapy for Chronic Pain that was 
issued in February 2017,\2\ initiation of long term opioid therapy for 
chronic non-cancer pain is not recommended, and instead non-opioid 
therapies are being utilized as first line therapies in a multimodal 
fashion. The challenge, however, is the patients already on long-term 
opioid therapy, with many on opioids for years, and often transferring 
care to VHA on opioid therapy. Based on the VA/DoD Opioid Practice 
guideline, opioid dosage adjustments in these patients should be 
individualized and sudden opioid discontinuation should be generally 
avoided. This patient-centered process will give Veterans time to 
adjust to new treatment options and to mitigate any patient 
dissatisfaction that may accompany these changes.
---------------------------------------------------------------------------
    \2\ Chou R, Deyo R, Devine B, Hansen R, Sullivan S, Jarvik JG, 
Blazina I, Dana T, Bougatsos C, Turner J.The Effectiveness and Risks of 
Long-Term Opioid Treatment of Chronic Pain. Evidence Report/Technology 
Assessment No. 218. (Prepared by the Pacific Northwest Evidence-based 
Practice Center under Contract No. 290-2012-00014-I.) AHRQ Publication 
No. 14-E005-EF. Rockville, MD: Agency for Healthcare Research and 
Quality; September 2014. Available at https://
www.effectivehealthcare.ahrq.gov/ehc/products/557/1988/chronic-pain-
opioid-treatment-executive-141022.pdf downloaded 2-24-2016.
---------------------------------------------------------------------------
    The opioid prescribing and risk mitigation parameters are all 
moving in the right direction, and 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 and are being studied 
as strong practice leaders. VA has trained all VHA prescribers about 
safe opioid prescribing and the heroin crisis, in response to the 
Presidential Memorandum Addressing Prescription Drug Abuse and Heroin 
Use\3\ and the Comprehensive Addiction and Recovery Act of 2016 (CARA).
---------------------------------------------------------------------------
    \3\ The White House Office of the Press Secretary. October 21, 
2015. Presidential Memorandum Addressing Prescription Drug Abuse and 
Heroin Use-Available at https://www.whitehouse.gov/the-pressoffice/
2015/10/21/presidential-memorandum-addressing-prescription-drug-abuse-
and-heroin downloaded 2-24-2016.
---------------------------------------------------------------------------
              state prescription drug monitoring programs
    Another risk management approach to support Veterans' and the 
public's safety is VHA participation in state Prescription Drug 
Monitoring Programs (PDMP). VA has implemented a regulatory change to 
enable VA prescribers to access information contained in these 
databases. These programs, with appropriate health privacy protections, 
allow for the interaction between VA and state databases so that 
providers can identify potentially vulnerable at-risk individuals. VA 
providers who register with the state PDMP can now access the state 
PDMP for information on prescribing and dispensing of controlled 
substances to Veterans outside the VA healthcare system. When all 
states are fully deployed, non-VA providers will also be able to 
identify their patients who may be receiving controlled substances from 
VA. Currently, VA transmits prescription data to all participating 
states. As of September 2017, 48 states and the District of Columbia 
are fully activated for PDMP data transmission, with two states that 
are not receiving transmissions from VA, Nebraska and Missouri. VA 
continues to work with Nebraska to establish transmissions, which were 
impacted by changes to the state's system, while Missouri does not have 
a statewide PDMP. In October 2016, VA released VHA Directive 1306, 
which requires PDMP use by controlled substance prescribers. 
Participation in PDMPs enables 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 available 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.
        va's opioid education and naloxone distribution program
    In certain situations, opioids may be the best choice for pain, 
even for patients with risk factors for overdose or suicide. In such 
cases, it is crucial that patients and those around them know how to 
prevent, recognize and respond to an overdose. Naloxone is an antidote 
to opioid-induced respiratory depression, which can cause death. With 
opioid use, risks are involved, and VA is taking precautionary steps to 
mitigate these risks. In May 2014, a VHA team developed and implemented 
VA's Overdose Education and Naloxone Distribution (OEND) program. This 
program facilitates system processes and trains clinicians in opioid 
overdose education and prescription of naloxone for use in the case of 
overdose. VA clinicians have adopted this practice at a rapid pace. As 
of October 30, 2017, over 11,150 unique VA prescribers stationed across 
all VHA healthcare systems have prescribed over 112,183 naloxone kits 
to Veteran patients. Using advanced analytics, VA has been able to 
target OEND to Veteran patients at highest risk of overdose or suicide, 
prioritizing getting this potentially life-saving intervention to those 
with greatest need. As a result of the Comprehensive Addiction and 
Recovery Act of 2016, co-pays do not apply to naloxone kits or overdose 
education training, ensuring that at-risk Veterans do not decline this 
important training and rescue intervention out of concerns over cost.
                  psychotropic drug safety initiative
    The Psychotropic Drug Safety Initiative (PDSI) is a VHA nationwide 
psychopharmacology quality improvement (QI) program that improves the 
quality of mental healthcare for Veterans across VHA by improving the 
access to and quality of psychopharmacologic treatments for Veterans' 
mental health needs. The PDSI program supports VISN and facility 
psychopharmacology QI initiatives through development and monitoring of 
performance metrics, clinical decision support tools, and virtual 
learning collaborative and educational resources. Since it was 
chartered by the Under Secretary for Health in December 2013, the PDSI 
program has worked closely in partnership with other VA initiatives to 
address the opioid crisis and needs of Veterans for addiction 
treatment.
    Reduction in inappropriate use of benzodiazepines has been a key 
focus of PDSI. This is important given the growth in use of 
benzodiazepines over the past decade that parallels the growth in use 
of opioids. When prescribed together, the risk of overdose death from 
benzodiazepines and opioids is greatly increased. Efforts through PDSI 
have had the following impact in reducing benzodiazepine use across VA:

  --During Phase I PDSI efforts (fiscal year 2013-fiscal year 2015):
      --42,000 fewer Veterans with PTSD received benzodiazepines;
      --2000 fewer Veterans with dementia received benzodiazepines; and
      --20,000 fewer elderly Veterans received benzodiazepines.
  --During PDSI II efforts specifically focused on older Veterans in 
        fiscal year 2015-fiscal year 2017:
      --Over 20,000 fewer older Veterans received outpatient 
        prescriptions for benzodiazepines or sedative hypnotics; and
      --Over 5,700 fewer Veterans with dementia received a prescription 
        for benzodiazepines.

    PDSI has also directly addressed the need for Veterans with opioid 
use disorder to receive evidence-based medication-assisted treatment 
(MAT). Early PDSI efforts (fiscal year 2013-fiscal year 2015) saw a 12-
percent increase in the proportion of patients with opioid use disorder 
treated with an opioid agonist therapy (national score increase from 
27.9 percent to 31.2 percent). Starting in July 2017, PDSI focused on 
improving access to MAT for Veterans with opioid use disorder and 
alcohol use disorder. Every facility in the country has identified one 
of those two areas of prescribing as a priority for their local 
psychopharmacology QI work and efforts are underway now to improve 
addiction treatment for Veterans across the system.
                   cara implementation and stop pain
    CARA was signed into law in July 2016 and is a comprehensive effort 
to address the opioid addiction epidemic. In accordance with this law, 
VHA is reducing reliance on opioid medication for chronic pain 
management, providing safer prescribing and monitoring practices, and 
moving towards a Veteran-centric, biopsychosocial care plan. CARA 
expands the comprehensive approach to Veteran care with enhanced 
patient and community interactions by improving access to the state 
prescription drug monitoring programs, conducting community meetings, 
and expanding the VA Patient Advocacy Program. The Office of Patient 
Advocacy was established on July 11, 2017, as directed by CARA Section 
924. The new office reports directly to the Under Secretary for Health. 
The Office of Patient Advocacy is a national program office that 
promotes the delivery of exceptional advocacy services to advance and 
influence patient driven healthcare, ensures appropriate training, 
accurate reporting and trending, and carries out the responsibilities 
detailed in the legislation. VHA is expanding its efforts in 
complementary and integrative health treatments through the development 
and execution of a strategic plan to expand complementary health, the 
execution of pilot programs in each VISN, and supporting a commission 
to provide additional recommendations.
    We are eagerly awaiting the final appointment of the Creating 
Options for Veterans' Expedited Recovery (COVER) Commission members, 
which will allow that Commission to begin its important work of 
exploring complementary and integrative treatment options. VHA has 
conducted reviews of the credentialing process during onboarding and 
off-boarding of clinicians. These reviews explore potential risk areas 
related to any license violations, which may impact their fitness for 
duty. CARA implementation continues to gain momentum through internal 
and external communications, pain management team implementations, 
program expansions, and education focusing on the health and safety of 
Veterans under our care.
    We recently announced the STOP PAIN effort in direct response to 
New Jersey Governor Chris Christie's call as Chairman of the 
President's Commission on Combating Drug Addiction and the Opioid 
Crisis. This effort brings together a comprehensive tool kit of best 
practices from CARA, Pain Management, Opioid Safety Initiatives, 
Academic Detailing, Opioid Use Disorder, and MAT.
                               conclusion
    While VA continues to prescribe opioid for pain treatment, we are 
actively researching alternatives and ways to reduce the number of 
opioids prescribed and distributed. While we know we still have work to 
do to improve in this area, VA has been at the forefront of this 
effort, and we will continue to do so to better serve the needs of 
Veterans.
    Thank you to Senator Capito and Senator Baldwin for requesting this 
hearing, and to the Chairman for holding it, so that we can bring this 
important issue to light. My colleague and I are prepared to respond to 
any questions you or the Subcommittee may have.

    Senator Moran. Thank you very much.
    Mr. Missal.
STATEMENT OF HON. MICHAEL MISSAL, INSPECTOR GENERAL, 
            U.S. DEPARTMENT OF VETERANS AFFAIRS
    Mr. Missal. Mr. Chairman, Ranking Member Schatz, Vice 
Chairman Leahy, and members of the subcommittee, thank you for 
the opportunity to discuss the Office of Inspector General's 
work relating to preventing opioid abuse. As you know, opioid 
abuse has become a serious public health emergency for our 
nation that impacts individuals and families from all walks of 
life.
    Our veterans have been particularly hard hit. It is not 
surprising that given the prevalence and complexity of chronic 
pain in the veteran population, overdose deaths among veterans 
occur at elevated rates when compared to the civilian 
population. With increasing opioid overdose deaths, the 
emphasis has appropriately shifted to opioid dose reduction, 
increased assessments, and closer monitoring of patients on 
chronic opioid therapy. My statement today will focus on the 
findings and recommendations from a recent report, ``Opioid 
Prescribing to High-Risk Veterans Receiving VA Purchased 
Case.''
    Because of its persistent nature, chronic pain is 
particularly problematic to treat and is often refractory to 
conventional treatments. Within the veteran population, pain 
management becomes even more complicated because veterans' 
chronic pain is often accompanied by post-traumatic stress 
disorder, traumatic brain injury, substance abuse, depression, 
and various other combat injuries. Due to the complexity of 
chronic pain in the veteran population, VA deployed two 
initiatives in 2014 to improve the safety and management of 
chronic pain in veterans, the Opioid Safety Initiative and the 
enabling of VA providers to participate in state prescription 
drug monitoring programs.
    While VA has responded aggressively to the opioid epidemic 
with the OSI, no such initiative is in place for veterans who 
are prescribed medications outside VA. Over the last several 
years, VA has implemented several Purchased Care programs to 
enable veterans to access medical care in the community, 
including the Veterans Choice program.
    My office conducted a health care inspection to review 
opioid prescribing to high-risk veterans receiving VA Purchased 
Care. The purpose of the review was to identify the extent of 
opioid prescribing by non-VA providers and potential related 
patient safety issues. Prescriptions for veterans who are 
authorized care through Choice are required to be filled at a 
VA pharmacy in order for the cost of the medication to be paid 
by VA. However, a veteran can choose to fill the prescription 
outside VA and pay for the prescription with his or her own 
funds.
    We found that with the expansion of community partnerships, 
a significant risk exists for patients who are prescribed 
opioids outside of VA. Specifically, gaps in health information 
exchanges between VA and non-VA providers can put patients at 
significant risk for serious medication interaction and 
unintentional or intentional overdose. Those especially at risk 
include patients suffering from chronic pain and mental illness 
who receive opioid prescriptions from non-VA clinical settings 
where opioid prescribing and monitoring guidelines may conflict 
with VA guidelines.
    We confirmed that with the challenges related to health 
information sharing, non-VA providers do not consistently have 
access to critical health care information on the veterans they 
are treating. For example, access to an up-to-date list of 
medications and a relevant past medical history is important 
for any provider when caring for a patient, but especially so 
with high-risk veterans, such as those with chronic pain and 
mental illness. Similarly, without immediate sharing of 
information, VA providers may also not be aware of treatment 
plans or new medications prescribed by non-VA providers.
    These gaps in care coordination are particularly risky when 
treatment plans by either or both groups of providers include 
opioid therapy. Requiring that all opioid prescriptions be 
filled by a VA pharmacy will help ensure that VA providers have 
information about all opioids prescribed to a patient by all 
providers.
    VA has made significant steps in battling the opioid 
crisis, but there is much more work to be done. Specifically, 
health information sharing between VA and non-VA providers has 
been a significant problem throughout the history of VA's 
Purchased Care programs. Rapid implementation of Choice limited 
opportunities to proactively design a streamlined and effective 
process for the coordination of care being provided to 
patients. OIG believes that the issues raised here today and 
included in our inspection report merit serious consideration 
as Congress and VA work together to revamp Choice.
    Mr. Chairman, this concludes my statement. I'm happy to 
answer any questions you or other members of the subcommittee 
may have. Thank you.
    [The statement follows:]

              Prepared Statement of Hon. Michael J. Missal
    Mr. Chairman, Ranking Member Schatz, and Members of the 
Subcommittee, thank you for the opportunity to discuss the Office of 
Inspector General's (OIG) work related to preventing opioid abuse. As 
you know, opioid abuse has become a serious public health emergency for 
our Nation that impacts individuals and families from all walks of 
life, and our veterans have been particularly hard hit. It is not 
surprising that, given the prevalence and complexity of chronic pain in 
the veteran population, overdose deaths among veterans occur at 
elevated rates when compared to the civilian population.\1\ With 
increasing opioid overdose deaths, the emphasis has appropriately 
shifted to opioid dose reduction, increased assessments, and closer 
monitoring of patients on chronic opioid therapy. My statement today 
will focus on some of VA's recent efforts in this area and the findings 
and recommendations from our recent report, Healthcare Inspection--
Opioid Prescribing to High-Risk Veterans Receiving VA Purchased 
Care.\2\
---------------------------------------------------------------------------
    \1\ Bohnert AS, Ilgen MA, Galea S, McCarthy JF, Blow FC. Accidental 
poisoning mortality among patients in the Department of Veterans 
Affairs Health System. Med Care. Apr 2011 49(4) 393 3962011;4):393-396
    \2\ Issued July 31, 2017. Available at: https://www.va.gov/oig/
pubs/VAOIG-17-01846-316.pdf.
---------------------------------------------------------------------------
                               background
    Because of its persistent nature, chronic pain is particularly 
problematic to treat and is often refractory to conventional 
treatments. Within the veteran population, pain management becomes even 
more complicated because veterans' chronic pain is often accompanied by 
post-traumatic stress disorder, traumatic brain injury, substance 
abuse, depression, and various other combat injuries. Due to the 
complexity of chronic pain in the veteran population, the Veterans 
Health Administration (VHA) developed and deployed two initiatives in 
2014 to improve the safety and management of chronic pain in veterans: 
the Opioid Safety Initiative (OSI); and the enabling of VA providers to 
participate in state prescription drug monitoring programs (PDMP), 
which are state-run electronic databases used to track the prescribing 
and dispensing of controlled substance prescriptions to patients. The 
OSI includes specific opioid management guidelines, a toolkit for 
prescribers that focuses on patient education, guidance on alternative 
therapeutic approaches to chronic pain, and an emphasis on patient/
provider collaborations to manage chronic pain. The OSI relies on data 
within VHA electronic health records (EHR) to identify patients who are 
prescribed opioids. This also allows identification of potentially life 
threatening concurrent benzodiazepine use.\3\ Veterans Integrated 
Service Network (VISN) and facility oversight committees are then able 
to make determinations as to which patients would be considered high 
risk. They can also identify providers whose prescribing practices are 
not consistent with the evidencebased OSI guidelines. Access to PDMPs 
allows VA providers to query state prescription drug monitoring 
databases to determine if non-VA providers have prescribed, and a 
patient has obtained, controlled substances outside the VA. OIG is 
currently looking at VA's compliance with several of these metrics 
within the OSI and we plan to publish our findings in 2018.
---------------------------------------------------------------------------
    \3\ Benzodiazepines belong to a class of drugs used to treat 
anxiety and in some cases for insomnia and muscle spasms. Chronic use 
can lead to physical and psychological dependence. Serious side effects 
including death can occur when combined with opioids. Jones, J. D., S. 
Mogali, et al. (2012). ``Polydrug abuse: a review of opioid and 
benzodiazepine combination use.'' Drug Alcohol Depend 125(1--2): 8--18.
---------------------------------------------------------------------------
    While VHA has responded aggressively to the opioid epidemic with 
the OSI, no such initiative is in place for veterans who are prescribed 
medications outside VA. Over the last several years, VA has implemented 
several purchased care programs to enable veterans to access medical 
care in the community, including the Veterans Choice Program (Choice), 
which was authorized by Congress under the Veterans Access, Choice, and 
Accountability Act of 2014.
   oig report: opioid prescribing to high-risk veterans receiving va 
                             purchased care
    The OIG conducted a healthcare inspection to review opioid 
prescribing to high-risk veterans receiving VA purchased care. The 
purpose of the review was to identify the extent of opioid prescribing 
by non-VA providers and potential related patient safety issues. We 
looked at the current volume of opioid prescriptions dispensed by VA 
pharmacies but written by providers participating in Choice. 
Prescriptions for veterans who are authorized care through Choice are 
required to be filled at a VA pharmacy in order for the cost of the 
medication to be paid by VA. However, a veteran can choose to fill the 
prescription outside the VA and pay for the prescriptions with his or 
her own funds. The potential for misuse of opioids increases when there 
is limited coordination between providers.
                                findings
    OIG determined that 13,928 of the 877,253 veterans who were 
prescribed opioid medications during fiscal year 2016 received the 
prescription from Choice providers or a combination of Choice and VA 
providers and filled it in a VA pharmacy. Those 13,928 veterans 
received a total of 85,729 prescriptions from October 2015 through 
September 2016. This figure does not include opioid prescriptions 
written by non-VA providers and filled by non-VA pharmacies at the 
expense of the veteran. In these instances, where a nexus does not 
exist between the pharmacy and VA, the opioid medications will not 
automatically be recorded in the patient's VA EHR, and are therefore 
not subject to timely medication reconciliation or other care 
coordination or risk oversight by VA. More work is needed to understand 
the magnitude of veterans impacted by this lack of coordination and 
oversight.
    OIG found that with the expansion of community partnerships, a 
significant risk exists for patients who are prescribed opioid 
prescriptions outside of VA. Specifically, gaps in health information 
exchanges between VA and non-VA providers can put certain patients at 
significant risk for serious medication interaction and unintentional 
or intentional overdose. Those especially at risk include patients 
suffering from chronic pain and mental illness who receive opioid 
prescriptions from non-VA clinical settings where opioid prescribing 
and monitoring guidelines may conflict with VA guidelines.
    VA has acknowledged the importance of and the challenges inherent 
in care coordination with non-VA providers. In its ``Plan to 
Consolidate Programs of Department of Veterans Affairs to Improve 
Access to Care,'' submitted to Congress on October 30, 2015, VHA, 
citing the Agency for Healthcare Research and Quality (AHRQ), stated: 
`` . . . care coordination involves deliberately organizing patient 
care activities and sharing information among all of the participants 
concerned with a patient's care to achieve safer and more effective 
care.''\4\
---------------------------------------------------------------------------
    \4\ Section 3.3, p. 21, citing https://www.ahrq.gov/professionals/
preventionchroniccare/improve/coordination/index.html. Accessed 
September 22, 2015.
---------------------------------------------------------------------------
    When a patient is referred for care through one of VA's purchased 
care programs, an authorization for care from VA should include all 
information related to that patient that is relevant to the care being 
requested from the non-VA provider. OIG confirmed that, with the 
challenges related to health information sharing, non-VA providers do 
not consistently have access to critical healthcare information on the 
veterans they are treating. For example, access to an up-to-date list 
of medications and a relevant past medical history is important for any 
provider when caring for a patient, but especially so with high-risk 
veterans such as those with chronic pain and mental illness.\5\ 
Similarly, without immediate sharing of information, VA providers may 
also not be aware of treatment plans or new medications prescribed by 
non-VA providers. These gaps in care coordination are particularly 
risky when treatment plans by either or both groups of providers 
include opioid therapy. VA has recently initiated the Community Viewer, 
a web-based application that allows community providers to access the 
VA EHR. OIG understands that this application will provide important 
information to community providers, which should result in more 
informed management decisions for those veterans receiving care outside 
of VA.
---------------------------------------------------------------------------
    \5\ The contracts in place with third party administrators who 
engage and manage Choice providers require that medical documentation, 
including information about prescribed medications, be submitted to VA 
within 14 days, but this standard is not routinely met. The failure by 
non-VA providers to provide timely documentation was exacerbated when 
VA entered into a contract modification with third party administrators 
which ``decoupled'' the payment to the providers from their obligation 
to provide records. We have previously reported on this issue (see 
appendix A for a list of relevant reports), and continue to recommend 
that VA enforce provisions in the contracts which require timely 
submission of complete clinical documentation.
---------------------------------------------------------------------------
                            recommendations
    Requiring that all opioid prescriptions be submitted directly to 
and filled by a VA pharmacy will help ensure that VA providers have 
information about all opioids prescribed to a patient by all providers. 
A recent study\6\ of the impact of the OSI found overall reductions in 
the number of patients being prescribed high-dose opioids, and a 
reduction in the number of patients on concurrent chronic opioid 
therapy and benzodiazepines. The success of the OSI is in large part 
attributable to opioid prescription data in the VA EHR that allows for 
appropriate monitoring of patients, including oversight by facility 
providers, pharmacists, and VISN and facility Pain Management 
Committees. Comparable monitoring does not exist for opioid 
prescriptions written and filled outside of the VA system unless a non-
VA provider or the patient makes the effort to notify VA or the VA 
provider routinely accesses the PDMP.\7\ In these instances, where 
proactive efforts are made, the patient's VA EHR can be updated 
appropriately.
---------------------------------------------------------------------------
    \6\ Lin LA, Bohnert ASB, Kerns RD, Clay MA, Ganoczy D, Ilgen MA; 
Impact of the Opioid Safety Initiative on opioid-related prescribing in 
veterans. National Center for Biotechnology Information website, 
https://www.ncbi.nlm.nih.gov/pubmed/28240996. Accessed June 19, 2017.
    \7\ The PDMP does not provide a fail-proof way to ensure access to 
prescription information. There are limitations to accessing the PDMP 
for patients who receive opioids in neighboring states or for providers 
who are not licensed by the state in which they care for patients. In 
addition, a provider would not likely access the PDMP when they are not 
prescribing controlled substances to the specific patient.
---------------------------------------------------------------------------
    While the ability to query PDMP databases is now available, VA 
providers are unlikely to access the PDMP unless they are prescribing 
controlled substances to a specific patient. Timely notification that 
veteran patients are receiving non-VA opioid prescriptions would prompt 
more immediate VA provider action when required. For example, if all 
routine non-VA opioid prescriptions were submitted directly to VA 
pharmacies, VA pharmacy staff could alert the VA provider of record 
that a non-VA opioid prescription was being dispensed. This would 
promote consistent pain management committee oversight by VA of opioid 
prescriptions prescribed by both VA and non-VA providers.
OIG recommended that the Under Secretary for Health:

  --Require that all participating VA purchased care providers receive 
        and review the evidence-based guidelines for prescribing 
        opioids outlined in the Opioid Safety Initiative.
  --Implement a process to ensure all purchased care consults for non-
        VA care include a complete up-to-date list of medications and 
        medical history until a more permanent electronic record 
        sharing solution can be implemented.
  --Require non-VA providers to submit opioid prescriptions directly to 
        a VA pharmacy for dispensing and recording of the prescriptions 
        in the patient's VA electronic health record.
  --Ensure that if facility leaders determine that a non-VA provider's 
        opioid prescribing practices are in conflict with Opioid Safety 
        Initiative guidelines, immediate action is taken to ensure the 
        safety of all veterans receiving care from the non-VA provider.

    VHA concurred with the recommendations. At present, all four 
recommendations remain open. We will continue to follow up with VHA 
until they are implemented.\8\
---------------------------------------------------------------------------
    \8\ As an added layer of transparency, our public website now 
provides real-time data on the implementation status of OIG report 
recommendations. This information is available at: https://www.va.gov/
oig/apps/info/OversightReports.aspx and https://www.va.gov/oig/
recommendationdashboard.asp.
---------------------------------------------------------------------------
                               conclusion
    VA has made some significant steps in battling the opioid crisis, 
but there is much work to be done. Specifically, health information 
sharing between VA and non-VA providers has been a significant problem 
throughout the history of VHA's purchased care programs. Rapid 
implementation of Choice, in particular, limited opportunities to 
proactively design a streamlined and effective process for the 
coordination of care being provided to patients. OIG believes that the 
issues raised here today and included in our inspection report merit 
serious consideration as Congress and VA work together to revamp 
Choice.
    Mr. Chairman, this concludes my statement. I would be happy to 
answer any questions you or members of the Subcommittee may have.

    Senator Moran. Thank you very much.
    Mr. Simcakoski, thank you very much for being here, and we 
welcome your testimony.
STATEMENT OF MR. MARVIN SIMCAKOSKI
    Mr. Simcakoski. My name is Marvin Simcakoski. And I am 
Jason Simcakoski's dad. My wife, Linda, is here with me today, 
and I speak out for our entire family, from Jason's daughter, 
Anaya, to his widow, Heather. We are all grateful for the 
bipartisan focus on the opioid epidemic facing our country, and 
especially our veterans. I'm grateful that you are holding this 
hearing today to hear from the VA on implementation of Jason's 
Law and some areas where the VA still needs improvement.
    I'd like to tell you a little story about my son, Jason. He 
was proud to be a Marine and to serve his country. He always 
wanted to be number one at what he did, and he was very 
successful in the Marine Corps. Jason loved his fellow Marines.
    While he was on base, Jason got his skull cracked open, and 
when he got out of the Marine Corps, he got help at the VA. I 
never expected that this help would ultimately lead to Jason's 
death. Quite simply, the VA gave him, gave Jason, too many 
drugs. As a family, we had a choice after Jason's death: we 
could either retreat into ourselves, just be angry, or we could 
channel our anger and our desire to fix this wrong so that no 
other family had to go through what we did.
    The last time I testified before Congress, it was March 30, 
2015. At that time, I said, ``If after today's hearing nothing 
major gets changed, then I think people will lose faith in our 
government. Let's not let all of this fade away, let's make 
some historic changes that we can all be proud to be part of. 
Give these veteran men and women a fighting chance for a bright 
future instead of a cloudy one from being over medded so that 
they know what it feels like to be normal.''
    Well, we did do something big, and we couldn't have done it 
without the two Senators sitting here today, Senator Tammy 
Baldwin and Senator Shelly Moore Capito, worked together along 
with Congressman Ron Kind and Gus Bilirakis to pass the Jason 
Simcakoski Memorial and Promise Act. Everyone put politics 
aside and actually focused on what was best for our veterans. I 
wish things around here could be like that.
    I'm grateful that this committee is helping to make sure 
that Jason's Law is fully funded. So I want to thank you all 
here today. We need to make sure that the VA stays track on and 
that the money spent to implement Jason's Law is actually 
getting to where it needs to go.
    Now that Jason's Law is in the books, we are moving forward 
with the reforms that needed to happen at the VA. However, 
while we are helping veterans who come to the VA, what about 
all the veterans who are using the Choice program? Our family 
is supporting the bipartisan bill that Senator Baldwin is 
putting forward to address the Inspector General's report from 
July that shows veterans receiving care outside the VA don't 
have the same opioid prescribing and monitoring guidelines that 
Jason's Law requires inside the VA. We need to stay vigilant, 
and I am going to work my hardest to see that this legislation 
also gets across the finish line.
    As a family, we know it's very real and tragic the way 
devastating consequences of opioid addition. I lost a son, 
others lost a brother, a husband, a father, and a friend when 
Jason lost his life. Nothing can replace his loss in our 
hearts, but as a family, we are determined to make a 
difference. We are committed to making sure that no other 
veteran or family has to experience this type of tragedy. I 
want veterans to have normal lives, not a life of dependence on 
any drug.
    In the near future, we are going to be setting up a 
foundation in Jason's name to help veterans like Jason lead 
normal and fulfilling lives, free from addition.
    I want to thank you all again for your work on behalf of 
our nation's veterans and my family. I know Jason is proud of 
all the work we have done, and he is smiling down on all of us. 
I can also hear his voice telling us to keep going, and that is 
what we are going to do.
    Thank you again.
    [The statement follows:]

                 Prepared Statement of Marv Simcakoski
    My name is Marv Simcakoski, and I am Jason Simcakoski's Dad. My 
wife Linda is here with me today and I speak for our entire family, 
from Jason's daughter Anaya to his widow, Heather. We all are grateful 
for the bipartisan focus on the opioid epidemic facing our country, and 
especially our veterans. I'm grateful that you are holding this hearing 
today to hear from the VA on implementation of Jason's Law and some 
areas where the VA still needs improvement.
    I'd like to tell you a little about my son, Jason. He was proud to 
be a Marine and to serve his country. He always wanted to be number one 
at what he did and he was very successful in the Marine Corps. Jason 
loved his fellow Marines. While he was on base Jason got his skull 
cracked opened and when he got out of the Marine Corps, he got help at 
the VA. I never expected that this help would ultimately lead to 
Jason's death. Quite simply, the VA gave Jason too many drugs.
    Over the last couple of years of Jason's life, I really got to know 
and understand how Jason struggled with his addiction problem only to 
have it fueled time and time again by doctors at the VA. I argued with 
my son's doctors for years about how I could see they were over-
medicating him. I was always told that I wasn't their patient, even 
though I was his Dad who truly cared about him a lot more than they 
did!
    They had him on uppers like Adderall in the morning and then 
downers like clonazepam and lorazepam. I watched Jason go up and down 
because he worked with us in the family construction business. He would 
be all hyper in the morning and then out of it in the late afternoon 
from all these meds that were killing him. When my son came home from 
one of his inpatient stays, the doctor had him on so many meds both 
Jason and I were confused by all the different meds he had to take. At 
one point, they had him on over 15 different medications, including 
opioids and benzodiazepines.
    The VA helped create and fuel my son's addiction problems. I have 
seen the devastating consequences of addiction. It changes people. It 
changed my son.
    Four days before my son died, he sent me a text while he was 
receiving inpatient treatment at the Tomah VA. He told me he couldn't 
take it anymore he was going crazy and he reached out to me to help 
him. I called various offices above his doctor and my son called me 
back and said within two hours someone was helping him. I met with his 
doctor the next day with my son and a patient advocate. When we all sat 
down in the room, his doctor turned and pointed to me and said that I 
caused her a lot of trouble. She said she spent 2 = hours in meetings 
because I went over her head and said she could have been taking care 
of my son. She also said I may know how to build houses and pound nails 
but I don't know anything about taking care of my son. This really hit 
me hard to have his doctor tell me I don't know how to take care of my 
son and I caused her a lot of trouble for trying to help my son who 
needed my help. The reason I called over her head is that my son wasn't 
receiving the care from her he needed.
    August 30th 2014, was the hardest and most painful day of my life. 
There isn't a day that goes by when I don't relive that morning. I 
regret leaving my son in his room alone that morning only to get a call 
hours later that he had stopped breathing. I still can't get that 
thought out of my head; I wish I would have been there for him. I loved 
my son and still do with all my heart and I miss him badly.
    As a family, we had a choice after Jason's death. We could either 
retreat into ourselves and just be angry or we could channel our anger 
and our desire to fix this wrong so that no other family has to go 
through what we did. The last time I testified before Congress, it was 
March 30th 2015. At that time, I said, ``If after today's hearing, 
nothing major gets changed, then I think people will lose faith in our 
Government. Let's not let all of this fade away, let's make some 
historic changes that we can all be proud to be a part of. Give these 
veteran men and women a fighting chance for a bright future instead of 
a cloudy one from being over medded so they know what it feels like to 
be normal. I think this is going to be a great chance to have all 
government parties' work together to show the veterans they all really 
do care. After all, these people should be the most important priority 
to all of us because they are the real life heroes of this country! I 
am proud my son was veteran and he will always be my HERO!''
    Well, we did do something big and we couldn't have done it without 
two Senators sitting here today. Senator Tammy Baldwin and Senator 
Shelly Moore Capito worked together, along with Congressmen Ron Kind 
and Gus Bilirakis to pass the Jason Simcakoski Memorial and Promise 
Act. Everyone put politics aside and actually focused on what was best 
for our veterans. I wish more things around here could be like that.
    Jason's Law strengthens the VA's opioid prescribing guidelines and 
puts in place stronger oversight and accountability for the care they 
are providing our veterans. For me, one of the most important parts of 
the law was having an independent patient advocate at all the VA 
Medical Centers, someone who is actually independent and is looking out 
for the veteran, not their employer.
    I'm grateful that this committee is helping to make sure that 
Jason's Law is fully funded, so I want to thank you all here today. We 
need to make sure that the VA stays track on and that the money spent 
to implement Jason's Law is actually getting to where it needs to go.
    Now that Jason's Law is on the books, we are moving forward with 
the reforms that needed to happen at the VA. However, while we are 
helping veterans who come to the VA, what about all the veterans who 
are using the Choice Program? Our family is supporting the bipartisan 
bill that Senator Baldwin is putting forward to address the Inspector 
General's report from July that shows veterans receiving care outside 
the VA don't have the same opioid prescribing and monitoring guidelines 
that Jason's Law requires inside the VA. We need to stay vigilant and I 
am going to work my hardest to see that this legislation also gets 
across the finish line.
    My wife and I are also staying active at the Tomah VA, where we 
have monthly meetings as part of the Veterans Experience Council. The 
Council takes feedback from Veterans and their families to help improve 
services at the VA. From once being told I didn't know what I was 
talking about to now having constructive meetings with people like 
Director Victoria Brahm to staff people who lead the pain management 
university--there is a world of difference at the Tomah VA. From an 
outsider's prospective, they are listening to people now and I'm never 
afraid to raise concerns to question what they are doing. The Tomah VA 
isn't perfect and they still have work to do, but I have a lot of faith 
in Director Brahm. I've emailed her at 8pm at night with a veteran who 
needs help and she'll email me back within the hour telling me she's on 
it.
    This is one way that my wife and I are staying involved in the VA, 
but we want to do more. As a family, we know in a very real and tragic 
way the devastating consequences of opioid addiction. I lost a son and 
others lost a brother, a husband, a father, and a friend when Jason 
lost his life.
    Nothing can replace this loss in our hearts, but as a family, we 
are determined to make a difference. We are committed to making sure 
that no other veteran or family has to experience this type of tragedy. 
I want veterans to have normal lives, not a life dependent on any drug.
    In the near future, we are going to be setting up a foundation in 
Jason's name to help veterans like Jason lead normal and fulfilling 
lives, free from addiction. I want to thank you all again for your work 
on behalf of our nations veterans and my family. I know Jason is proud 
of the work we have done and he is smiling down on all of us. I can 
also hear his voice telling us to keep going and that is what we are 
going to do.
    Thank you.

    Senator Moran. Thank you very much for your testimony. I 
have no doubt that while you're very proud of your son, you and 
Linda are proud of your son, he's very proud of you, and we're 
honored to have you with us today.

                     IMPLEMENTATION OF JASON'S LAW

    Let me ask you this. I mean, your story and your family's 
experiences, it's devastating to all of us. We're--almost 
without exception, we're all parents, we love our kids, and we 
want good things to happen. We put faith in government, we put 
faith in the Department of Veterans Affairs, and sometimes our 
faith is not rewarded.
    So we're pleased that Jason's Law has passed, and we're 
here today to make certain that its implementation is effective 
for individuals like your son, in the position of needing help 
from the Department of Veterans Affairs, and that they're cared 
for. And, again, your leadership is helpful, significant in 
that regard.
    You indicated you testified in March of 2015. Can you 
describe for me, for us--and I know that you're actively 
involved in your local VA hospital, Tomah VA Medical Center. 
Could you describe for me how you think things are different 
today for a veteran that would be in the same circumstance your 
son was when he was there, how significantly different it is? 
You've heard Dr. Meyers' testimony about policies and 
procedures put in place. Do you see it different when you're in 
the hospital and when you talk to veterans and their family 
members at home?
    Mr. Simcakoski. Yes, I do. And my wife and I, we meet once 
a month at Tomah. We're on the Veterans Experience Council. And 
the Director, Victoria Brahm, is the head of the council. And 
there are a lot of staff members that participate in the 
monthly meetings. And, you know, we go over and discuss things 
new things, you know, that we want to be put in place to help 
the veterans.
    And also, you know, there have been significant changes 
since my son passed away. Well, first of all, there's a new 
Director, a new Chief of Staff, you know, and a lot of the 
other people that were problematic at the Tomah VA are gone 
now. But, you know, we see a better atmosphere there. People 
aren't afraid to talk anymore. Before, it was, you know, what I 
thought, it was more like a dictatorship run place, when my son 
was there, you know.
    Even talking with the patient advocate, for example, she 
argued with me about my son's medications. And I asked her, I 
said, ``So you're a doctor now, too?'' because she thought that 
I didn't know anything. And she was sticking for the facility, 
which I thought she represented the patient.
    Secondly, the doctors that were there at the time with my 
son, my son was afraid he was going to get kicked out of the 
facility because he didn't know how the doctor would feel 
because I went over his doctor's head because she wasn't doing 
anything to help my son at the time. My son sent his last text 
message to me was, ``Dad, you have to help me. I can't take it 
anymore.'' And the doctor wasn't doing anything to help him. 
She made him take a prescription that was totally wrong for him 
and made him go crazy, and he told her that, and she told him 
that if he didn't take it, he was kicked out of the facility.
    So, basically when I went over her head and talked to 
somebody else at the facility, next when I went back over 
there, she walked in the room with me, she said to me, you 
know, I'll still never forget that she said, ``Mr. Simcakoski, 
you may know how to pound nails and build houses, but you don't 
know anything about your son. And you made it worse by going 
over my head.'' And I'm like, ``No,'' I said, ``I'm trying to 
help my son.'' And, my son kept us apart because he was afraid 
that he was going to be kicked out of there.
    I mean, you don't get that, the atmosphere is pretty gone 
by the wayside now. Now you can bring things up. I mean, I can 
email Victoria Brahm at 7:00 at night on a veteran that 
contacts me that needs help, and she emails me back that same 
night and says, ``I'll take care of it,'' and she's giving him 
a call the next day. So it's definitely a much better and 
positive atmosphere there now.
    Senator Moran. You do highlight something that I've seen. I 
mean, I have parents who come to me to tell me their son or 
daughter needs surgery or they don't believe they're getting 
the care they need from the VA, but their son or daughter tries 
to convince them not to talk to me, that visiting with me may 
have consequences in their care and treatment that they're 
receiving. And, again, you wouldn't expect that from anybody at 
the VA; you certainly wouldn't expect it from a patient 
advocate.
    Do you, Mr. Simcakoski, do you and Linda, your wife--do you 
talk to, network with, other veteran families across the 
country? And what you've experienced in Wisconsin, is it 
anything that you know is happening elsewhere? So the 
improvements that you see, the attitude, the approach is 
different. Do you have a sense that that's beyond your own 
hospital or your own community, or do you know that?
    Mr. Simcakoski. No, we get contacted from other veteran 
families. A lot of them contact us for help, and who do they 
talk to? Also a lot of them are congratulating us on the effort 
and thanking us for all the changes that have been made, not 
just in the VA, but in the private sector also. I know 
hospitals in our state that cut down on the amount of opioids 
and things like that given out to patients because of what 
happened to Jason.
    And, some people were mad. Some people would say, ``Hey, 
you know, we can't get the same pain meds now because of what 
happened with your son.'' I'm like, ``Well, you know, I'm just 
trying to save your life. If you don't like that, you know, 
that's up to you, but, ``I said, ``Look at what happened to our 
son. The ultimatum was death.''
    I mean, you can only go so high with medications, and, I 
mean, once you're maxed out, there's no place to go but, death. 
I mean, really. It's just like with alcohol or anything else. 
You can only take, tolerate--your system can only tolerate so 
much of it.
    Senator Moran. It's true in conversations that we have, 
casework in our office, in which the complaint will be, ``I no 
longer can get the medications that I need or have had in the 
past,'' so there's pushback because of the addiction.
    Mr. Simcakoski. Right. Well, people have to realize that 
opioids don't help heal the process, they just mirror it, and 
sometimes it prolongs the process of the healing. I mean, I 
just had aortic aneurysm surgery in April, and, everybody said, 
``You've got to take pain meds,'' Well, I took two different 
days in the hospital and that was it, and then I took Tylenol, 
and I had major surgery. I mean, I'm cut all the way up. So, I 
mean, people can say what they want, but, you know, your system 
gets used to it.
    That's just like chronic pain, you take chronic pain, and 
everybody has chronic pain. Well, I'm in the construction 
business my whole life. I've had walls knocked on me, on my 
neck, my back. I deal with chronic pain. I don't take a pain 
med every day. I learn to deal with it. I wake up slow and 
sore, but I get by, and I'm fine. I'm 60 years old, and I don't 
ever plan on taking them, period. And I know what my body is 
telling me.
    So there are other alternatives. There's yoga, there's 
alternative therapy, which I think is, something great that, 
and the VA in Tomah is implementing a lot of different things 
right now for, other care besides pain meds. That's not the 
answer.
    Senator Moran. Thank you for your testimony today and for 
the role you're playing in changing the world for the better.
    Mr. Simcakoski. Thank you.
    Senator Moran. You're welcome.
    Senator Schatz.
    Senator Schatz. Thank you, Mr. Simcakoski. I really 
appreciate everything you've done over the many years and the 
sacrifice that you've made.

                            PAIN MANAGEMENT

    My first question, is for Dr. Meyer, and following up on 
this conversation. So you've changed your standard of care, 
you've tightened up the prescribing, you're tracking the 
opioids better. So the question I have is, what do you do about 
physical pain? And to what extent, when you look at this 
crisis, do you think of this as also a psychiatric problem; in 
other words, that some people are doing self-medicating related 
to other ailments that they have coming home, especially from 
combat missions? So what's the new standard of care in terms of 
pain management? How far along are you in terms of whatever 
research you think needs to be completed? What's the new gold 
standard?
    I mean, I understand the first thing, the easy thing. 
Right? Is to reduce the availability of opioids, but what do we 
do about pain? And how do we prevent people from, if they are 
drug seeking and they can't get the opioids at VA, that they go 
and chase it someplace else? So I'm wondering how we actually 
treat the veteran now that we've reduced the availability of 
the pain medication.
    Dr. Meyer. Exactly. And I think it has to be tailored to 
each veteran and each patient independently. Back pain is 
different than neck pain or chronic headache after a closed 
head injury. And so you have to engage with that veteran and 
convince him or her to take all of the different modalities of 
pain and try and find out what works best for them. Often for 
low back pain, the active therapy is yoga, tai chi, and 
conventional physical therapy are all very good modalities. We 
also offer acupuncture, but that works for some, but not for 
everyone. And so the----
    Senator Schatz. I want to just stop you there because, you 
know, I'm the son of a principal investigator, so I understand 
the need to kind of prove out all the alternative treatment 
modalities.
    Dr. Meyer. Yes.
    Senator Schatz. But I'm just wondering whether there's not 
a space before you do all your double-blind studies and 
establish that the stuff works, if you don't look at it another 
way, which is if you're--diversion, right? So maybe you don't 
get these people self-reporting that the pain is less, but if 
they're not taking opioids, that gets to be considered a 
positive outcome.
    In other words, if someone does yoga or acupuncture or 
dance or art or whatever it is, that's success already, you 
don't have to get the clinical data to indicate that their pain 
is reduced. Am I making sense to you here?
    Dr. Meyer. Yes. And I think we're doing that. We're both 
engaged in research, but also actively engaged in extending the 
reach of complementary and integrated health and making those 
modalities available everywhere and encouraging their use in 
individual cases across the board. We're also looking at 
studies to see what modalities work best where and extending 
those, and we're actively seeking better research to guide our 
future practice, but that's not stopping us from implementing 
these now.

                         OPIOID ABUSE AND PTSD

    Senator Schatz. And so to what extent is--so this is sort 
of a different topic, but how much of this problem is not the 
person who comes in, gets overprescribed, and becomes an 
addict, but, rather, someone who's experiencing psychiatric or 
psychological pain and ends up self-medicating because they're 
trying to blot out whatever is going on with them in terms of 
their own personal psychiatric situation?
    Dr. Meyer. So the scenario you describe of a veteran with 
both chronic pain and mental health issues or PTSD is very 
common in the VA, much more common than in the general civilian 
population, but it's across the board. And so that's another 
reason why it has to be--the treatment has to be tailored to 
the individual, often involving mental health. If somebody has 
already been on long-term opioids, they may well be dependent 
on those and, frankly, have an opioid use disorder that they're 
not willing to admit at this point. And so these become very 
intertwined.
    Senator Schatz. Right.
    Dr. Meyer. And you have to individualize that therapy. It 
can take a lot of engagement of individual veterans.
    Senator Schatz. This is the last question. Is there a 
particular phenomenon--this is what has been described to me by 
combat veterans, and I don't know how to label it clinically, 
but it's the kind of heightened state that you're in when 
you're in combat, the adrenaline pumping, that sort of clarity, 
the ``excitement'' is the wrong word, but that heightened state 
of being alive, and the structure and the meaning that comes 
from that life, and then coming home and just not being able to 
match that.
    And I don't know whether there's a clinical phenomenon 
that's been sort of--that's been named and categorized, but I 
just wonder whether that is something beyond the anecdotal, 
that actually you understand happens, and how you deal with 
that in terms of I guess it's probably psychiatric terms.
    Dr. Meyer. Yes, that certainly can be part of the PTSD 
spectrum. I've seen it in people without PTSD as well. I've 
been a practicing physician in the VA for 35 years. And so, 
yes, I'm aware of it, and, yes, it is. It interacts with this 
whole issue of health.
    Senator Schatz. Thank you.
    Senator Moran. Senator Collins.
    Senator Collins. Thank you, Mr. Chairman. Let me start, Mr. 
Simcakoski, with thanking you so much for coming forward with 
Jason's story. And I just want to assure you that your advocacy 
has made a real difference, as is evident in the law that 
Senator Baldwin and Senator Capito authored. And your being 
here today will continue to help us make progress. So thank you 
for that.

                        OPIOID SAFETY INITIATIVE

    Dr. Sandbrink, when I look at the statistics in Maine, 
they're very discouraging. Last year, 376 people died from 
overdoses. This year, we're on track for the exact same number, 
being if you look at where we are this year, it looks like 
we're going to have a very similar number of deaths, despite 
all of these efforts.
    The VA in Maine has implemented an Opioid Safety Initiative 
that is intended to reduce the number of patients who are 
receiving in excess of 100 morphine equivalent dose. And the 
chart is encouraging in that it's going down in terms of the 
number of veterans receiving opioids. What I would like to know 
is, how do you track the number of opioids prescribed per 
veteran within the VA system and for those veterans who are 
being treated outside of the VA system?
    Dr. Sandbrink. So in regard to the veterans who we take 
care of within our system and within the Veterans Health 
Administration, as Dr. Meyer pointed out, the Opioid Safety 
Initiative, when it was initiated in August 2013, actually 
that's when it, you know, was expanded nationwide, includes a 
dashboard and the ability to track opioid prescribing in regard 
to multiple parameters. This is a dashboard that gives us an 
overall assessment of where we are in the Department of 
Veterans Affairs in regard to opioid prescribing. It can be 
then drilled down to our regional networks, or Veterans 
Integrated Service Network Liaisons (VISNs), to each facility, 
and then to each provider.
    In regard to the parameters that we track, we have the 
total number of opioids, the opioid and benzos co-prescribing, 
the patients who are on high-dose opioid therapy, as well as 
the implementation of the risk mitigation strategies such as 
urine drug screens.
    For instance, you know, I actually was in communication 
with the team lead at the main VA in Togus, and you had 186 
patients I think on high-dose opioid prescribing, about 100 
milligrams of morphine equivalent. The same numbers could be 
obtained from any other facility relatively easily within our 
dashboards. And we can track down at each facility who is the 
actual prescriber for each of these medications.
    Senator Collins. So, Dr. Meyer, when you discover that a 
prescriber is an outlier, what do you do?
    Dr. Meyer. So we have a program called Academic Detailing 
that's modeled after the obviously successful pharmaceutical 
company detail men that go around and advertise drugs. And so 
these dashboards are used to direct the activity of these 
generally PharmDs to go around and do one-to-one education. So 
those providers are individually identified and counseled. They 
become quickly aware that their prescribing practices are under 
review, and they are--the management of their patients is 
discussed with them and alternatives. That is incredibly 
successful, and we can show that as that gets implemented where 
it is targeted is you see a greater reduction and a greater 
appropriate use of safe prescribing practices.
    It is inappropriate to cut off high-dose or even--you need 
to both engage the patient, give them alternative therapy for 
their mental health, for their pain, and then gradually taper 
them. We know that if you simply taper, especially abruptly 
taper, without providing that support, you increase both 
suicide and overdose because people seek drugs from alternative 
sources.
    So what we've seen across the VA is we've implemented the 
combination of the dashboards, education, and this very 
specific Academic Detailing, is that we're seeing a very steady 
decline in every single VA with high-dose prescribing, and the 
charts are just amazing. It drops down in every facility. 
There's a lot of spread between facilities because that's the 
way they started, but each one is making what we feel now to be 
appropriate progress. And if there's a facility or a provider 
that's out of line, they get identified and educated.
    Senator Collins. Thank you.
    Senator Moran. Senator Baldwin.
    Senator Baldwin. Thanks to the committee chair and ranking 
member for holding this hearing and particularly to all of the 
members relating to the action our committee has taken to fully 
fund the provisions of CARA that are the Jason Simcakoski 
Memorial and Promise Act.
    Marv, I want to again thank you for being here and sharing 
Jason's story, and for yours and Linda's and Heather's and 
Anaya's continued commitment to the care that veterans receive 
and turning your tragedy into hope for others.

                          VA PATIENT ADVOCACY

    You shared a story in your answers to the chairman's 
questions about the role of the Office of Patient Advocacy, and 
I think those are really important. And, you know, we tend, in 
looking at the Jason Simcakoski Law, Jason's bill, to focus on 
the retraining of prescribers and the ability to track their 
prescribing in real time, et cetera, but the role of a patient 
advocate is really critical. And I wonder if you can explain a 
little bit in more detail what was happening, what wasn't 
working right, with the patient advocate role in the Tomah VA. 
And then I'm going to ask Dr. Meyer a question about the new 
Office of Patient Advocacy and its stand-up right now.
    Mr. Simcakoski. Well, you know, like I said, the patient 
advocate at the time when my son was in the VA in Tomah, my 
wife and I didn't feel like they were representing the 
patients' best interests at all. It seemed like they were 
working for that facility and answering to that facility's 
Director or Chief of Staff. And, to me, I mean, it was 
troubling because, we're trying to--we're going to this person 
because, that's who the patient--was supposed to be working for 
the patient and, instead, it seemed like it was completely a 
different case.
    In our son's case, I know it was because I said, we just 
didn't get along at all because of the way, we were treated. 
Basically our family was treated like, we didn't know anything 
and we were dumb, and this person knew what they were talking 
about medically and about our son, which I don't even know at 
the time if she even met our son.
    But, yeah, it wasn't a good situation. And, I mean, 
obviously something has to change. And that's why, the patient 
advocate office should be not with the facility that they work 
for, it should be an independent office, so that that person 
doesn't have to worry about consequences from helping that 
patient at that facility.
    Senator Baldwin. If I recall the sort of chain of command, 
the patient advocate was answering to or supervised or directed 
by the supervising physician who was actually treating Jason 
that was sort of the chain of command rather than an 
independent advocacy.
    Mr. Simcakoski. That's correct, yes.
    Senator Baldwin. Okay. Dr. Meyer, can you please provide us 
with an update on how the new Office of Patient Advocacy is 
working to improve communication with veterans and their 
families, to provide education and training that would empower 
patients, and making sure that office has the resources and 
tools that they need to assist veterans, particularly those 
recovering from opioid addiction and struggling with chronic 
pain?
    Dr. Meyer. So I can tell you what I do know. And the Office 
was established I believe in June or July. It's stated in my 
testimony, I believe July 11th. And I do know that it's 
established. I have talked to them, and I know they're active. 
I'm aware of the memos that go out, but they are independent 
from the Pain Service and from me. They do respond directly to 
the Under Secretary. So it is a high-level office.
    Something I was just talking to Mr. Simcakoski about 
before, that what I haven't personally done is call a local VA 
and assure that the connection is made and find out what would 
happen if I did that. And I think that's something that I 
should take responsibility for doing, but I haven't done yet. 
I'm sorry.
    Senator Moran. Senator Boozman.

                      OVERPRESCRIPTION OF OPIOIDS

    Senator Boozman. Thank you, Mr. Chairman. Opioid 
overprescription abuse is truly a severe problem in Arkansas, 
as we discussed, and is so much so throughout the country. 
According to a recent report by CDC, Arkansas has the unwelcome 
distinction of being second only to Alabama in its writing of 
opioid prescriptions.
    A few months ago, the Arkansas Health Department shared a 
sobering statistic that I want to share with you all. In 2016, 
235.9 million opioid pills were sold in Arkansas, three opioid 
prescriptions for every Arkansan. That is enough for every man, 
woman, and child in the state to take 80 pills. And so because 
of that, as all of us here really do take this issue very, very 
seriously.
    I was pleased that just yesterday the University of 
Arkansas Agriculture Extension Service received a $322,000 
grant from USDA to develop complementary and alternative pain 
management interventions to reduce opioid abuse and misuse 
among rural Arkansas residents. The project will focus on 
bridging the access gap and on increasing awareness of opioid 
risk and treatment alternatives.
    Arkansas has also received funding from the Health and 
Human Services for nine community health centers in 2016-2017 
to help combat the opioid epidemic. Health care centers like 
the ones in Arkansas have seen a 55 percent increase in the 
number of veterans they serve from 2008 to 2016, in large part, 
due to the implementation of the Choice program in 2014.
    All of these are great examples of how all corners of the 
Federal Government are working to stem the tide of opioid 
overprescription abuse, which can benefit veterans.
    I guess the question is, how is the VA working with other 
Federal agencies to address the opioid epidemic? How are we 
working together? And for Arkansas, it's especially important 
to address the unique needs of rural pain sufferers, many of 
which are veterans. What are you doing specifically to address 
the pain management needs of veterans in rural areas?
    Dr. Meyer. So thank you, Senator Boozman. First, the VA 
does sit on the intergovernmental task--the White House called 
task force on opioid management. So I'm actively engaged in 
that, and I represent the Under Secretary in that. So we are 
trying to coordinate responses so we don't allow any piece of 
the puzzle between HHS, DOD, Border and Customs to fall down in 
between the cracks. And we're working to, for example, make 
sure that we all have better PDMP access is an easy example. So 
I hope that continues and can be as successful as all of us, 
you know, imagined it might be.
    With respect to rural veterans, the VA does have the Office 
of Rural Health, and so portions of that funding go to a lot of 
different areas, but one of them is for training providers in 
rural areas in both pain management and in substance use, is an 
easy example. We're very aware of the needs for rural veterans, 
and ironically, the Choice Act or the new proposed CARA 
legislation does not always solve those issues because there 
are regional shortages of all providers, both in and out of the 
VA, and that's someplace where telehealth can help.
    And so the provision of direct-to-home telehealth is 
something the VA is expanding enormously. The goal for next 
year is to have 5 percent of all veterans have at least one 
touch by the health care system not in a VA hospital or clinic. 
It could be--it could in a library if that's where they have 
broadband because not all veterans have broadband. But this can 
be delivered on a cell phone.

                       VA ADAPTIVE SPORTS PROGRAM

    Senator Boozman. How about--and very quickly because we're 
running out of time--how about adaptive--how about other 
alternatives like adaptive sports and things either at the 
center or out in the communities? Tell us what you're doing in 
that regard.
    Dr. Meyer. We can certainly refer people out for 
alternative therapies in the communities where they're 
available. I am not familiar with adaptive sports specifically 
as an option in rural areas, but we can. Does that answer the 
question?
    Senator Boozman. No, I think so. I think----
    Dr. Meyer. I'm trying to cut it short.
    Senator Boozman. No, I understand.
    Dr. Meyer. I can go on.
    Senator Boozman. No, no, I understand. I guess the thing I 
would say, I think those things are really very, very 
important, the camaraderie, the sense of achievement, you know, 
doing something different.
    But, again, thank you, Mr. Chairman.
    Senator Moran. Senator Tester.
    Senator Tester. Yeah, thank you, Mr. Chairman and ranking 
member. I want to thank all the panelists for being here today.

                         VA ENVIRONMENT OF CARE

    Mr. Simcakoski, thank you for being here. I've got to tell 
you, your story was gut-wrenching. I appreciate you being here. 
It's a tough situation, and I appreciate you and your wife 
being good parents.
    By your testimony, you indicated that the patient advocate 
was the problem, and the chain of command of the patient 
advocate was the problem. And were there other things that were 
a problem other than that?
    Mr. Simcakoski. Yes, there was. That was just one of the 
many problems. They didn't have a crash cart on the floor. The 
nurse wasn't--didn't know what to do. She panicked. My son was 
left for about 15, 20 minutes without anybody doing anything to 
help him. They didn't know if he was dead or alive. They didn't 
have a defibrillator on the floor.
    Senator Tester. Got you.
    Mr. Simcakoski. There were numerous sorts of things----
    Senator Tester. So let me go over here to Dr. Meyer.
    Dr. Meyer, are a crash cart, a defibrillator on the floor, 
are those things standard operating procedure in VA hospitals?
    Dr. Meyer. Yes. And we do have programs, the Environment of 
Care, that should be overseeing that at all places. I've not 
gone back and looked and seen what happened at that VA on that 
occasion, I can tell you.
    Senator Tester. Okay. It might be important to go back and 
review and make sure that the checks and balances that are in 
this system are actually working. I don't know, how long have 
you been with the VA?
    Dr. Meyer. I've been at the Salt Lake VA for about 35 
years.
    Senator Tester. Yeah, so you've got a little bit of 
experience.
    Dr. Meyer. Oh, yeah.
    Senator Tester. So I think, you know, really getting to the 
bottom to make sure--what happened to this family should never 
happen. And we all know opioids are bad news. I had a friend 
that had throat cancer that if they wouldn't have grabbed him 
and hauled him off to treatment, he'd have committed suicide, 
there's no doubt in my mind about it, or he'd have just died.
    I want to talk to you, Mike, and thanks for being here. You 
reported on two case summaries. Would you classify those two 
case summaries as being typical?
    Mr. Missal. I think the description of each of them is not 
untypical of what we find. They both showed that veterans with 
a number of issues getting care in both VA and outside VA. We 
don't know how many there are, but we would think they're very 
similar to other issues that we have out there.

                     TRACKING OPIOID PRESCRIPTIONS

    Senator Tester. You talked about prescriptions, if we 
really want to be able to track them, need to be prescribed by 
the VA. To be honest with you, in rural areas of this country, 
it becomes pretty tough to do, especially when you need 
whatever prescription it is yesterday. And it's one of the 
challenges that we really have I believe with unfettered access 
to the Choice program and not being able to monitor these folks 
to be able to determine what's being done to them, prescription 
drugs taken.
    Assuming that every drug can't be given out by the VA, 
which I don't believe is possible, what other move--what other 
moves should we make in that regard?
    Mr. Missal. I think coordination of care is the real key 
here, and I think that's the challenge VA is going to face. As 
more veterans are getting care out in the community, to the 
extent that there is not coordination between the providers and 
the pharmacies, you're putting veterans at greater risk.
    Senator Tester. And that--okay. And that coordinator would 
be a VA doctor?
    Mr. Missal. It could be a VA doctor. VA does have mail-
order pharmacies as well, so you don't have to have one around 
the corner from you. So there are alternatives that VA can use.

                ALTERNATIVE AND COMPLEMENTARY THERAPIES

    Senator Tester. Okay. Sounds good.
    And this is for you, Dr. Meyer or Dr. Sandbrink. You talked 
about alternative treatments. Do you have a number of how many 
alternative treatments you're looking at right now to replace 
opioids?
    Dr. Meyer. You mean in terms of encounters or modalities?
    Senator Tester. Yeah, how many, Mr. Simcakoski talked about 
yoga.
    Dr. Meyer. Yeah.
    Senator Tester. Look, there are other things out--I mean, 
I've read that marijuana can help. How many different 
alternative----
    Dr. Meyer. There are probably at least 20 total. They're 
not all available at every site.
    Dr. Sandbrink. So in November 2016, the Health Services 
Research & Development arm of the VA, the research arm, had 
what is called a state-of-the-art conference in regard to 
nonpharmacological treatments for pain----
    Senator Tester. Yeah.
    Dr. Sandbrink. Nonpharmacologic and nonintervention 
treatments.
    Senator Tester. Yeah.
    Dr. Sandbrink. And they collected basically the information 
and evidence since this report about the promising or 
potentially helpful modalities, and it was categorized into 
psychological modalities, which include CBT, cognitive 
behavioral therapy, acceptance and commitment therapy, 
mindfulness therapy, mindfulness-based stress reduction----
    Senator Tester. Marijuana?
    Dr. Sandbrink. Marijuana is not based on that evidence 
since this report. The other that I want to mention were yoga 
and tai chi and exercise programs and the movement therapies, 
and then spinal manipulation, massage, and acupuncture.
    Senator Tester. So if I might, Mr. Chairman, just one 
thing, and that is, I think that the ranking member makes a 
good point. You need to really get them tricked out so you can 
use them if you're going to have a replacement, you can study 
them to death.
    The other point is, that this is what Mr. Simcakoski talked 
about is how you have teach people how to deal with pain 
without drugs is really important, and it can be done because 
we've all done it at some point in time in our lives. And so I 
would just encourage that.
    Thank you, Mr. Chairman.
    Thanks to the panelists.
    Senator Moran. Senator Murkowski.

                         ALTERNATIVE THERAPIES

    Senator Murkowski. Thank you, Mr. Chairman.
    Gentlemen, I want to continue along the same lines that 
Senator Tester was pursuing in terms of some of the 
alternatives to opioids. And I was recalling that some time ago 
we were dealing with a VA that was pretty limiting in terms of 
alternatives that were available for our veterans, and I had 
recalled several different discussions with young guys who were 
returning at that time from Iraq, and bodies beat up pretty 
hard by being in vehicles that didn't have much suspension and 
wearing heavy body armor. And rather than being given 
chiropractic care or physical therapy, the prescription was 
just take the pill.
    And at that time, you'll recall, the number of visits that 
were allowable for that veteran were--the chiropractic visits 
were limited. I think they were like 11 visits or was less than 
a dozen, which to me was incredible. So we go ahead and we'll 
prescribe the pill, but we're not going to help you kind of 
manipulate and move that body and help that body recover.
    So we're talking about a whole host of different 
alternatives, which I think is great, whether it's chiropractic 
or acupuncture or equine-assisted therapeutic activities, I'm 
all over this, I think it's great. But are we in the same 
situation that we were several years back where we are limiting 
the number? We've got some arbitrary number out there that 
says, okay, when you hit 20 appointments of acupuncture or 25 
chiropractic visits, you're done. And recognizing again that 
for many of the people in my state, going to a VA facility is 
not a possibility. So they're going to be going out onto the 
community for this.
    How is this going to work? And what can you--how can you 
assure me that this level of care, which in many cases, 
physical therapy can go on for months and months and months and 
months, how do we address that?
    Dr. Meyer. So thank you. Yeah, I think your state is 
predominantly rural, as is Senator Tester's. It's not unique.
    Senator Murkowski. Mm-hmm.
    Dr. Meyer. And you have a very hard situation there.
    What we've tried to do and are trying to do as we negotiate 
the care and the community aspects of the Choice Act is we're 
responsible for overseeing that care, and we're trying to come 
up with the best ways to do that, and this certainly involves 
pain, but it involves all kinds of stuff. And so we are not 
going to be limiting people to an episode, but neither do we 
want to approve one at a time over and over again because that 
becomes a bureaucratic nightmare.
    And so what we're trying to establish is episodes of care 
that might be, let's say, 15 or 20 episodes of chiropractic 
care, but then they could be extended. So you wouldn't have to 
go back and approve every one, but neither do you get a blank 
check. I don't think it would be responsible either from the 
point of view of the taxpayer or from overseeing veterans' care 
to simply turn somebody over and not make sure that care was 
needed and effective.
    So we're trying to walk the line, and I can't say what the 
limit is at all, I don't think we've established one for 
chiropractic care, but----
    Senator Murkowski. Well, I used chiropractic as an example, 
and I think it's a good one.
    Dr. Meyer. Yeah. Mm-hmm.
    Senator Murkowski. And I think it also recognizes the fact 
that everybody is different, everybody is going to heal 
different. Some people are not as good at their physical 
therapy as they should be. And so when we have kind of that 
arbitrary limit, if you will--and I understand that you can 
have some level of oversight that says, okay, after this many 
visits, you have to get kind of a re-up, if you will.
    But I will tell you, as one who was in physical therapy for 
many, many months after a pretty serious recreational injury, 
nothing like our veterans would ever do, to be on a physical 
therapy bed and have the person next to me crying, not because 
she was in pain, but because she was being told by her physical 
therapist that her number of treatments was up with her 
coverage, and she couldn't get any more. And she said, ``I'm 
not done, I still hurt, I still need you.''
    And I don't want our veterans to be in that same situation 
where they feel they can't get that continued care, there is 
this gap. So you've taken them off the opioids, which is the 
place that they should be trying to go, but we need to make 
sure that we're working with them. And I fear that as we're 
moving into this Choice where you have different issues and 
different places and rural states are clearly going to see this 
impact that we've set up a tough situation for those vets who 
cannot get that care in a VA facility.
    Thank you, Mr. Chairman. My time is expired.

                          VA CHIROPRACTIC CARE

    Senator Moran. I want to use the opportunity of Senator 
Murkowski's line of questioning to highlight that back in my 
House days, we passed legislation requiring the VA to implement 
chiropractic care within each VISN. In my view, the VA was slow 
in its implementation of that and didn't seem to embrace that 
concept. The Senate has now passed legislation requiring 
chiropractic care in every VA hospital. My understanding is the 
VA is about halfway--that bill has not yet become law, but the 
VA has about half of their hospitals that provide chiropractic 
care. But the point that the Senator from Alaska raises, there 
are circumstances in which there is no chiropractic care at 
all, let alone the number of visits that a patient, a veteran, 
can see. Am I missing something, Dr. Meyer?
    Dr. Meyer. I think your characterization--I don't have the 
numbers at my fingertips, but I think it's globally accurate. 
And the VA is in the process of upping its game in chiropractic 
care. I know that it's also dangerous to extrapolate from one 
VA, but in my own VA, I was both a requestor and an approver at 
different times of extended services. So specifically for 
physical therapy, we had patients in Idaho, and, you know, we 
would say they've had their 12 visits, let's re-up, it's 
working. And so I know that occurred in at least one VA 
routinely.
    Senator Moran. Thank you very much.
    Senator Udall.
    Senator Udall. Thank you, Mr. Chairman and Ranking Member 
Schatz, for holding this hearing. Incredibly important.

            VA INFORMATION SHARING WITH COMMUNITY PROVIDERS

    Mr. Inspector General, you seem to conclude in your report 
that significant steps have been made and moved forward in the 
Veterans Administration to resolve this, but the thing that 
seemed to worry you the most is that health care information 
sharing between the VA and the non-VA providers has been a 
significant problem throughout the history of the VHA's 
Purchased Care program. And so you've made recommendations 
about this.
    My questions are to the VA. What steps have you taken, 
knowing these recommendations have come in, to better tackle 
this problem of the Choice program being set up and having 
providers getting opioids out here, and then also getting 
opioid prescriptions within the VA? What specifically have you 
done to resolve this?
    Dr. Meyer. So that's actually handled by two different 
offices. But I'm aware of the work and I think I can speak to 
it. One is that we've established--I believe in Mr. Missal's 
written testimony he mentioned the Community Viewer, which is 
now in existence and is rapidly being rolled out. So that 
allows outside providers to see the VA records of that veteran. 
And once that's fully implemented, I think it will be the best 
solution.
    Senator Udall. When will that be fully implemented?
    Dr. Meyer. I'm not sure of the time scale. I hope in this 
calendar year. I think that's a fair estimation. And I can get 
back to you on that as a follow-up question.
    Senator Udall. Okay.
    Dr. Meyer. I'm sorry, I just don't have that. However, we 
already have implemented an automatic request and note 
generator that when the consult is made, pulls elements out of 
our electronic record that includes recent lab tests, 
prescription records, problem lists, and recent notes, and that 
it's usually about a 20-page packet that goes to the outside 
provider at the time of the request. So that helps them on 
their side.
    We're also trying to get better access to their records, 
but providers use all different kinds of systems outside the 
VA. I don't think care coordination between providers and 
different systems is unique to the VA and those not. It's seen 
across the health care spectrum.
    So I'd like to think that the VA is doing at least as good 
a job, if not better, than some others. And we're aggressively 
tackling it. So I hope that we really have the access of 
outside providers to VA records solved this calendar year or, 
excuse me, 2018.
    Senator Udall. Yeah. Mr. Inspector General, have they done 
enough? Have they moved quickly enough? Are these the kinds of 
things that you believe will resolve this?
    Mr. Missal. These are the things that are going to help. 
You can always do more. One of the recommendations we had in 
the report was that the medication histories be provided to the 
outside providers so they can see what this veteran has had 
before, and it assists the provider in the care that they would 
be giving.
    And so we're going to be checking. They have agreed to 
implement that, and we will ensure that they fulfill it and do 
it in a sustainable way. But this is one of the big challenges, 
and while care in the community certainly has its benefits, it 
creates other challenges as well. And in our opinion, 
coordination of care may be the biggest challenge, and it's not 
going to be easy to resolve.

               OPIOIDS AND THE NATIVE AMERICAN POPULATION

    Senator Udall. In New Mexico, we not only have the rural 
health care issue we've talked about, but we also have a huge 
issue in terms of Native Americans and Native American 
veterans. What is the Veterans Administration doing to approach 
that particular issue, Native American veterans and dealing 
with the opioid crisis?
    Dr. Meyer. So New Mexico I think has been a leader in rural 
health. And the Extended Health Care Option (ECHO) program was 
developed down there, as I'm sure you know, and so the VA has 
been heavily involved with that specific program. And, indeed, 
I was just in Albuquerque for the national meeting of that 
recently.
    We're using, as I mentioned, I think to Senator Tester, 
we're using--or was it Senator Boozman? The telehealth 
modalities extensively, and then the ECHO program uses 
teleconferencing to allow education of providers in more rural 
areas. Now, the issue is we do have clinics out there, but we 
still need to make our reach farther.
    And so the Native American population in Utah or, excuse 
me, in New Mexico does tend to be extremely rural, and in other 
areas, it's urban. And so they do have different demographics 
and different prevalence of some diseases. And I think we're 
aggressively working on pain, on hepatitis C, on other issues 
that are more prominent in Native American populations. And 
we're, you know, again, the Indian Health Service actually uses 
a different version of our health system, and I know they are 
considering merging with the same electronic health record that 
we and the DOD anticipate using. And so if that comes to pass, 
it will make care coordination even easier.
    Senator Udall. Yeah. Thank you very much. And thank you for 
your work on this.
    Senator Moran. Senator Capito.
    Senator Capito. Thank you, Mr. Chairman, and I thank the 
ranking member.
    And I want to thank my colleague Senator Baldwin for 
working on this issue with the Simcakoski family.
    And it's nice to see both of you again, and thank you for 
your advocacy and your bravery really for just keeping it up, 
keeping it going.
    I have a couple questions, and the more I sit here, the 
more questions I get, because I don't think that what's going 
on at the VA in terms of conflicts or in not being able to get 
enough data about opioids is any different than what's going on 
in the general public. Sometimes we use the VA as a good 
example of, ``Well, let's do this in the general public,'' and 
sometimes we use the general public to say, ``Let's try this at 
the VA.''

                VA COMMUNITY CARE PRESCRIPTION PRACTICES

    When my colleague from Arkansas said that they had the 
second highest opioid prescribing rate, I'm not proud to say 
that we used to have that distinction in West Virginia. In 
2006, we prescribed 129.9 per hundred people; and it's down to 
1996, which is still not so great. But it does show you that if 
you begin to monitor and if you begin to keep track and you 
have accurate records and you shine a light on this, you can 
improve the situation and you can make a difference. And so I 
would say that that's an important takeaway from this.
    But here's where my concern is: if you have a veteran who 
goes to community care and is prescribed an opioid, first of 
all, I think we obviously have to fix the loophole that the VA 
records should be able to reflect that, if at all possible. My 
understanding is they have to fill that prescription at the VA, 
is that correct?
    Dr. Meyer. So what we're actively implementing in response 
to the Inspector General, and also in response to Senator 
Tester's concern about availability, is that if somebody is 
writing--and we battered back and forth numbers--less than 
seven days of an opioid, they can get it at an outside 
pharmacy, but they can get the first seven days elsewhere. Then 
following that, they need to use one of the VA's mail-order 
pharmacies. And that makes it available. But I would point out 
that the VA uses the state PDMPs, and the pharmacies do, and 
the VA providers are required to check that as well for, in all 
cases, for chronic prescriptions. So we do have that kind of 
exchange.

              STATE PRESCRIPTION DRUG MONITORING PROGRAMS

    Senator Capito. Do you in every VA, are you monitoring 
what's going on at the state monitoring drug program?
    Dr. Meyer. Yes. I can't say that every single provider 
every single time follows each state and VA guidelines, but 
we're working on it.
    Senator Capito. Right. So if you have a VA that straddles 
different states----
    Dr. Meyer. Of which there are many.
    Senator Capito. Do they avail themselves of every state?
    Dr. Meyer. Yes. So I----
    Senator Capito. That didn't sound so affirmative there.
    Dr. Meyer. I can give you--but it's hard.
    Senator Capito. I know. I know. Because it's reflected in 
the general public. That's been part of the problem.
    Dr. Meyer. North Florida/South Georgia, we have to write 
because you have to be licensed in South Georgia.
    Senator Capito. Right.
    Dr. Meyer. You have to write a consult, somebody who is 
licensed. There are two different pieces of legislation going 
through, and the VA has submitted suggestions to that 
legislation to allow us to check even in states in which we're 
not licensed and to allow surrogates to check for us.
    Senator Capito. Absolutely have to do that.
    Dr. Meyer. My preference would be for an automated system 
to allow that check-in and have it imported into our medical 
record automatically. That would greatly relieve the reliance 
on the mechanics of the provider.
    Senator Capito. Right.
    Dr. Meyer. A MD getting in, which is a considerable 
administrative workload.
    Senator Capito. Well, we should be able to do that. I mean, 
we need to do that because, as you said, a lot of VAs straddle 
different and I understand the licensing issues, but I also 
understand that in pursuit, sometimes the veteran is no 
different than the general population in the pursuit of 
medications that maybe they can't get one place, they're going 
to find out a way to get it. One of the ways I realized they 
were doing in West Virginia for a time was instead of using 
their insurance card or their credit card, they're paying cash, 
and it's not going into the system because it's not set up for 
that. And I hope we've gotten rid of that loophole as well.

                       ADVERSE DRUG INTERACTIONS

    I'll just close and say that Andrew White was a young 
veteran who returned home to his family in late 2007. He went 
to the VA in Huntington, West Virginia. It wasn't opioids so 
much, but it was conflicting medicines. He was on a whole 
cocktail of a lot of different medicines and in tremendous 
pain, PTSD. He couldn't figure out what was wrong with him. He 
became a different person. And one day he didn't wake up in his 
own home. And I'm convinced, as his parents are convinced, and 
the VA has looked at this, too, that the combination of what he 
was taking was just too much for him.
    And so I know you've worked hard at the VA to try to look 
at different conflicts. And this sort of melds into opioids, 
but it doesn't necessarily mean that it's an opioid 
prescription. It can be the opioid prescription on top of 
everything else. So I think we can do better. I appreciate your 
efforts. I do think that if you look at what's going on in the 
charts of states like mine and Arkansas where you see 
improvements, those are the same places you can make 
improvements through the VA, and our veterans are certainly 
well deserving of that.
    Thank you.
    Senator Murphy. Thank you very much, Mr. Chairman.
    Thank you all for your testimony.
    Mr. Simcakoski, thank you very much for being here and 
sharing your story with us. And thanks to Senators Baldwin and 
Capito for all their great work on this.

                         ALTERNATIVE THERAPIES

    So in the private sector, one of the biggest barriers to 
this conversion away from dependency on pain medication is the 
willingness or the lack of willingness on behalf of the 
insurers to pay for alternatives. And so there's a supply 
issue. There's just not enough access there on the private 
sector side when it comes to all of these alternative pain 
therapies that we've talked about here today. And maybe you've 
answered this in response to other questions, but is there a 
capacity issue in the VA? If you continue to be successful in 
moving patients away from opioid treatment, is there any 
capacity issue with respect to physical therapy or acupuncture 
or chiropractic, all of the different places that you might go?
    Dr. Meyer. Yes, there is. And we're seeking to expand those 
options as actively as we can. We have shortages in many of the 
physicians. We also have shortages in many of the other health 
professions. Not all VAs have a full suite of complementary and 
integrated health, and so they need to go to the VISN centers. 
And has been pointed out, in rural areas that can be basically 
prohibitive for one way or another. So, and in some cases 
they're not available in the communities either. So the VA is 
working to expand access.
    Senator Murphy. And what do you need from Congress in order 
to expedite that improvement of access?
    Dr. Meyer. So the complementary and integrated health teams 
are expanding in tracking that. They do have support to do 
that, but it is just simply a slow process. I think you can 
continue to encourage that and monitor that, and that's always 
actually appreciated.

                         PAIN MANAGEMENT TEAMS

    Senator Murphy. Mr. Missal, you had a section of your 
testimony related to breakdowns in the coordination of care. 
And one of the problems especially with multimodal therapy is 
that, you know, it takes a different degree of coordination to 
get to all of those appointments, to organize transportation, a 
lot easier to take a pill and go to the prescription--to go to 
the pharmacy once.
    Can you just drill down a little bit more on what you found 
needs to be done better when it comes to coordination, in 
particular, the amount of coordination necessary to help 
veterans who are in multimodal therapy? There's a study at the 
clinic in San Antonio that identified a lot of these barriers 
that existed to multimodal therapy.
    Mr. Missal. Right. Part of what VA is trying to do now is 
to do more of a team approach, to have pain management 
specialists on those teams. And what they're going to have to 
do then is get it out to the community. That's why the more 
they can coordinate their care, the more information sharing. 
And so that would involve education, it would involve training, 
and also technology. As was pointed out, right now there are so 
many different kinds of health records out there that don't 
talk to one another. So the more they can figure out the back 
end in terms of getting the records that can better speak to 
one another or to be better shared, the more effective it's 
going to be.
    Senator Moran. Senator Schatz.

                          MEDICINAL MARIJUANA

    Senator Schatz. Thank you, Mr. Chairman. I think this 
question is for Dr. Sandbrink. I would like to insert for the 
record a summary of a study conducted from 1999 to 2010. It's 
in the Journal of the American Medical Association, October 
2014 issue. And here is the abstract.
    I'll just summarize the results. Three states have medical 
cannabis laws effective prior to 1999. Ten states enacted 
medical cannabis laws between 1999 and 2010. Now, here's the 
most important thing. States with medical cannabis laws had a 
24.8 percent lower mean annual opioid overdose mortality rate 
compared with states without medical cannabis laws. So 25 
percent reduction when medical cannabis is available in terms 
of opioid deaths.
    Now, I know that this isn't the end of the scientific 
inquiry, but this is pretty compelling data to me. And I also 
understand that the VA is a Federal agency. So I want to set 
aside the question of statute, and I want to ask you your 
clinical opinion. Do you view this data as persuasive in terms 
of what appears to be an inverse relationship between the 
availability of medical cannabis and the overuse and eventually 
overdose related to opioids?
    Dr. Sandbrink. Yeah, thank you very much. Clearly, there is 
an association, there is some kind of correlation going on that 
was pointed out in that study.
    Senator Schatz. Could you summarize it for me? I want to 
hear it in your words because I'm not the clinician here.
    Dr. Sandbrink. You know, as you just summarized for those 
states that have implemented cannabis laws and implemented the 
availability of cannabis for medical purposes, that there has 
been a 25 percent reduction, about 25 percent reduction, of 
overdose deaths. In that regard, obviously, that's a very 
important finding. I think we need to understand what is truly 
providing this what seems to be a protection or reduction of 
overdose deaths. I think there are, and I think there is 
increased evidence for medicine.
    Senator Schatz. Well, do we? I mean--sorry to interrupt for 
a moment. You do? You need to do the academic and scientific 
inquiry to try to figure out really what's going on here right? 
At the physiological level or psychiatric or whatever. But I'm 
not sure we need to know exactly why it's working to use it for 
policy-making purposes. Do you see what I'm saying?
    Dr. Sandbrink. Yes.
    Senator Schatz. I see you nodding, Dr. Meyer. Would you 
like to weigh in without getting yourself in trouble?
    [Laughter.]
    Dr. Meyer. I walk that line a lot. So again thank you. I 
don't think we can wait to have the perfect evidence for 
everything. I would concur with you. And if you have evidence 
that something is working, you don't need to figure out why 
it's working I'm talking in very general terms here in order to 
employ it. The VA is in the position of being required to 
follow the statutory law. And so, as Federal employees, we're 
prohibited from recommending marijuana.
    I think one of the things that we do in the practice of 
pain medicine and medicine in general, including mental health, 
is that we can, while we can't recommend medical marijuana, we 
don't have to, for example, stop opioids because it's being 
used. And so if people would--if Congress would change 
regulations, we would have more freedom both to investigate and 
to give therapy.
    Senator Schatz. To prescribe or recommend.
    Dr. Meyer. Yes.
    Senator Schatz. And this would be--I assume that until you 
go through an FDA process and all the rest of it, you're not--
most doctors are not prepared, you know, really to treat it 
like medicine, but you probably would be comfortable to treat 
it like yoga or like physical therapy or like any of these 
other--you know, Senator Tester was getting to this point. It's 
sort of betwixt and between in terms of, is it medicine? You 
know, maybe not. Does it help? Almost certainly. And so where 
do you put that as a doc?
    Dr. Meyer. Or even as we would with herbal medicine, for 
example. I think that might be a better example for right now 
in this case. So, yeah.
    Senator Schatz. Thank you.
    Senator Moran. Senator Baldwin.

                       VA OPIOID SAFETY TRAINING

    Senator Baldwin. Thank you. I just have a couple of closing 
questions, and I appreciate the opportunity to have another 
quick round on this, to really focus squarely on the gaps that 
exist. And, you know, earlier today, Senator Capito and myself, 
the chairman, also Senator Tester, others of our colleagues on 
a bipartisan basis, introduced legislation to further some of 
the recommendations contained, Mr. Missal, in the Inspector 
General report released earlier this year.
    We've talked about a lot of the essential and critical 
components of Jason's Law in the VA, the training of 
prescribers, implementing the latest CDC guidelines that focus 
both on drug interactions as well as the safest opioid 
prescribing practices, implementation of Patient Advocacy 
Office, the Patient Advocacy Office, and strengthening that in 
all of our VA health institutions, pain management teams, and 
real-time tracking of prescribing.
    Now, certainly in terms of gaps that have been identified 
in the Veterans Choice program and other community care 
programs, we can't necessarily take all of those components 
that I view as critical and, you know, for example, real-time 
tracking of prescribing. But you've prioritized, you've 
identified some of the most important. You haven't talked as 
much about training and basically requiring an understanding of 
the VA's adoption of the CDC latest guidelines, but that's a 
key part of this. So I wonder if you could expand on that.
    Mr. Missal. Sure. One of our recommendations in the report 
is that all non-VA providers need to receive and review the OSI 
guidelines. Within those guidelines, it does talk about many of 
the things that you mention, including education and training. 
And so when we make recommendations, we do it because we've 
identified an issue and we think this is going to be an 
appropriate solution. VA has agreed to do that. So we will be 
monitoring their progress to implement that. And I think many 
of the things you talked about would be included in there and 
perhaps in some of our other recommendations, and we're going 
to be watching this very carefully to make sure they get 
implemented.
    Senator Baldwin. Okay. And, Mr. Chairman, if I could just 
end on a note where you began. We're very pleased that you have 
a seat both at the authorizing table and the appropriating 
table on this, and I have appreciated your leadership. I know 
that this isn't the only gap that has been identified in terms 
of creating a seamless passage for our veterans between VA care 
or care within VA facilities and care in the community or 
Veterans Choice. I am glad that you are tackling that with our 
colleagues on the authorizing side. And I hope, as a sponsor of 
this important, more narrowly focused piece, that you'll share 
that with your colleagues on the authorizing side, too.
    Senator Moran. Senator Baldwin, thank you for your lobbying 
efforts.
    [Laughter.]

                 DEPARTMENT OF VETERANS AFFAIRS BUDGET

    Senator Moran. It allows me the opportunity to indicate 
that we are the committee, or subcommittee, members should know 
the Choice program expires when the funding for this year comes 
to a conclusion. That's currently estimated to be at the end of 
December. The VA is not always perfect in its estimates. And 
while our CR expires December the 8th, the question is, where 
are we after December the 8th? And I don't have a clear 
understanding where that is.
    But in addition to the expiration of the program--let me 
outline why I think that's significant. One, veterans would no 
longer be able to use Choice. Two, the intermediaries, the 
providers, the TriWest in our case, the Health--Health--
HealthNet. How can I forget their names? HealthNet. Those 
people may go away. Their networks would disappear, and 
restarting Choice again becomes much more complicated than if 
we can continue the program.
    So Congress has a lot of burdens on its back at the moment, 
one, to get us out of the CR, and to do that, will give us the 
money we need to fully fund Choice into the future and keep 
Choice alive and well. Mr. Missal may have a lot less concerns 
about what's going on in community care if the program no 
longer exists. In my view, veterans in Kansas and across the 
country will be misserved, underserved, in the absence of 
community care.
    We also have another challenge, and this is where the 
Budget Control Act (BCA) caps come into play, in this as well 
as many other instances. The plan, and I think it's the right 
one, is to consolidate all community care under one program so 
that Choice and the community care programs that the VA already 
had before Choice become one pot of money. And from my 
perspective, a good change that will occur, that is planned to 
occur, is that mandatory spending will go away, be replaced by 
discretionary spending, and this subcommittee and the 
Appropriations Committee, and ultimately the entire Senate and 
Congress, will then have control over how we spend money in 
community care, a broader category than the mandatory spending 
of Choice and the community--discretionary spending under 
community care.
    So we need to be working with our leadership in the Senate 
and the House and with the administration in getting us to a 
point that when December the 8th comes, we have a plan in 
place, and I hope it's not another CR perhaps beyond a few 
days, to deal with the expiration of Choice and the creation of 
a community care account within the VA to deal with all 
community care programs in that one account, and then becomes 
the jurisdiction of this subcommittee, at least for the 
appropriations process.
    Incidentally, your lobbying has been successful, and 
Senator McCain and I and others are working with the 
authorizing committee to introduce an extension, a 
reauthorization of the Choice program, and our draft of that 
bill already includes the Capito-Baldwin legislation that we've 
described today.

                     VA COMMUNITY CARE COORDINATORS

    It also, Dr. Meyer, includes requiring the VA to have a 
community, a care coordinator within the VA to monitor and to 
manage the care of a veteran when he or she is receiving care 
outside the VA so that there is a VA person within your 
hospital in Utah who is monitoring the care.
    And I think it goes to part of the solution that Mr. Missal 
has sought, is somebody needs to be paying attention to where 
that veteran is, where the prescriptions are being filled, and 
in what circumstances they're being played in a sense with the 
inside the VA, outside the VA, and private pay. I don't know 
that we can get to the private pay, but maybe.
    And a large part of what I think Mr. Missal has highlighted 
for us and Mr. Missal, I'm just going to say this privately, as 
we left, I think you're doing your job very well. Then it 
dawned on me that every time I have a town hall meeting, I 
listen to all the complaints, and as I walk out door, someone 
whispers in my ear, ``I think you're doing a good job.'' So I 
decided to say it publicly.
    [Laughter.]

                     VA ELECTRONIC MEDICAL RECORDS

    Senator Moran. It is, I think, a very important task you 
have, and I think you are performing that task admirably, but I 
think a significant component to this--and here we go back to 
what I was saying earlier about a CR and the BCA caps--we also 
have an issue here of electronic medical records, and we are up 
against a timeframe in which the VA and its coordination with 
the Department of Defense in implementing a new contract for 
electronic medical records across the system, there are 
efficiencies and economies of scale that occur when we do this 
in conjunction with the Department of Defense.
    The Department of Defense is starting in Washington State. 
We need to appropriate the money. The money that is needed to 
implement that contract will exceed the budget control caps. 
And, again, for another reason, as it relates to our care and 
treatment of veterans, we need to get something done in 
December so that the VA can further its contracting obligations 
and get electronic health records implemented in conjunction 
with the Department of Defense in the cost saving way that I 
think makes sense in a timely fashion.
    And I think it comes back again to the testimony that we've 
had today, the nature of this hearing, which is that then has a 
consequence upon the VA's ability to monitor the prescribing 
and the use of opioids and other prescriptions that it will 
otherwise not have. Not only is that computer system, those 
electronic health records, to coordinate with DOD and the VA so 
we have a more continuous seamless system in which you leave 
the DOD and come to the VA, but also to coordinate within the 
VA medical health records, and now the issue that arises 
because of your report, how do we coordinate? How do we have 
electronic medical records that are compatible with the medical 
records system outside the VA when we contract with an outside 
provider? That's where I don't want to discourage us from doing 
everything we can today, but it seems to me that electronic 
medical records are a significant key to solving the issues 
that you raise in your report. Am I missing something?
    Mr. Missal. No, I think you said that extremely well.
    Senator Moran. That's what I complimented, so you would 
answer the question that way. Thank you.
    [Laughter.]
    Senator Moran. Let me just ask a couple questions, then 
we'll conclude this hearing.

                  HIGHLY ADDICTIVE PRESCRIPTION DRUGS

    In particular, I want to know if while we're focused on 
opioids, I want to make sure we're not missing something else. 
So is there another drug? Is there something else that we ought 
to be worried about so that if we ultimately get opioids under 
control and they're managed and utilized in the appropriate 
way, have we missed some other thing that's either with us 
today or coming in a direction that is dangerous and harmful to 
veterans as a drug?
    Dr. Meyer. So there are other drugs with the potential for 
abuse, certainly benzodiazepines, amphetamines, some of the 
muscle relaxants do come to mind. Many of those are also 
subject to the same electronic oversight that we give. 
Certainly, we're including benzodiazepines in.
    Senator Moran. So the policies that the VA is implementing 
related to opioids really is broader. When we use the word 
``opioid,'' we're talking about a broader category of dangerous 
prescription drugs? Okay.
    Dr. Meyer. The OSI is specifically focused on opioids, but 
we're not blind to that. And we have not seen an uptick in 
other drugs' prescribing. Opioids are clearly the big problem.
    Senator Moran. Let me ask a question that then raises at 
least to me, which is, If we're diminishing the use of opioids 
within the VA, are we increasing the use of something else that 
is dangerous in its place?
    Dr. Meyer. No.
    Senator Moran. Good.
    Mr. Missal, did your investigation, your IG report, only 
deal with opioids, or it was broader in scope than that one 
particular drug?
    Mr. Missal. We focused in on opioids, but obviously some of 
the fixes for opioids then could be applied to other drugs as 
well when you get into the coordination of care because then 
that means all the other drugs being utilized, including 
opioids, would be included.

                      NON-VA PRESCRIBING PRACTICES

    Senator Moran. Do we have any statistics that demonstrate 
that a veteran has, as a result of opioid or other drug 
addiction and abuse, has died in the category of community 
care? Are there examples of circumstances of death, where the 
prescription occurred outside the VA?
    Mr. Missal. I don't have that information in front of me, 
but this is not a problem just limited to VA. It occurs 
throughout the United States.
    Senator Moran. I didn't ask my question very well. My 
question is we've heard from Mr. Simcakoski and what his family 
has endured within the VA. We're now focused on community care. 
Are there instances of death that resulted from prescriptions 
of opioids, the use of opioids, because of the circumstances 
you describe in your report; in other words, prescriptions that 
are within community care?
    Mr. Missal. Right. Given the extensiveness of care in the 
community at more than 30 percent, I don't have a specific 
example here, but there likely are a number of instances where 
the prescribing practices, and perhaps not having all the 
information, did result in a tragic situation.
    Senator Moran. Did you examine your report in this instance 
is about community care and your recommendations on how the VA 
needs to improve its oversight and practices within community 
care. Have you looked at the VA, I need to refresh my memory. 
Have you looked at the VA for opioid policies and 
implementation of this law within the VA, exclusive of 
community care?
    Mr. Missal. Not specifically, but we do have a report 
coming out on pain management and VA's approach to it. So it's 
going to be much broader than opioids. It's going to be 
covering a lot of different medications. And we should have 
that out in 2018.

                   OPIOID PRESCRIBING ACCOUNTABILITY

    Senator Moran. Thank you. Do we have examples of where 
individuals within the VA or community providers outside the 
VA, through Choice or community programs, have been fired as a 
result of their behavior, their activities, in regard to opioid 
prescription and utilization?
    Dr. Meyer. I'm aware of such cases in the VA. Those are, of 
course, an HR issue, but that has happened. I would think that 
we can't really fire an outside provider, but what we can do is 
seek to contract with them, and also, if appropriate, report 
them. I believe there are outside providers again, so that's 
done through essentially a contracting office using a third-
party arrangement, and I'd be very surprised if that hadn't 
happened.
    Senator Moran. If you would, Dr. Meyer, report back to the 
committee of the indications of the number of instances in 
which a contract has been terminated because of bad behavior 
related to prescribing utilization of opioids and other harmful 
drugs. Does that make sense?
    Dr. Meyer. I will, yes, it does, and yes.
    Senator Moran. My point there is I want to make certain 
that the VA is making certain there is a consequence to the 
behavior that we're trying to get at, and if there is a 
problem, then that contract provider, even though it may be 
through HealthNet or TriWest, those people ought not be 
involved in the Choice program. We do not, I'm a supporter of 
Choice, as is most Members of the Senate. We do not want to 
taint that program because of bad behavior. It needs to be 
eliminated, not tolerated.
    Dr. Meyer. I would add that's opioids and other behavior as 
well, sir.
    Senator Moran. Thank you.
    Mr. Missal. Mr. Chairman, one of the recommendations in our 
report is that VA needs to examine that, and if there are any 
providers outside of VA who are practicing inconsistent with 
the OSI, the Opioid Safety Initiative, then they should be 
removed as a provider, and VA agreed to that recommendation, so 
they'll be in the process of doing that.
    Senator Moran. Great. You asked my question so much better 
than I did, and that's the information I'm looking for, is 
apparently what you've already agreed to do in response to the 
IG report.
    And it's somewhat related to this question, but I was 
interested to know if there are already ongoing investigations 
into, unrelated in a sense, responding to the IG report, is the 
VA on the ball sufficiently to be investigating this behavior 
of inappropriate prescribing of opioids and other dangerous 
drugs? Thank you.
    I think I'm coming to a conclusion.
    Mr. Schatz, do you have anything else?
    Senator Schatz. No.
    Senator Moran. I think I'm done.

                       VA CARE COORDINATION TEAMS

    I did mean to ask you, Dr. Meyer, I mentioned that our 
reauthorization of the Choice program would include care 
coordinator teams, require that within the VA to monitor and to 
be responsible for a veteran who is receiving care outside the 
VA. In your professional opinion, does that concept have merit?
    Dr. Meyer. Yes. So in my professional opinion, there are a 
couple of faces to that challenge. One is the coordination of 
care that we've been talking about, and the other is the 
oversight of the quality of that care. And neither one of those 
offices are automatically stood up. And I would also point out 
that when we do then send that care out, as we will have to 
take on these additional functions, and that's work that 
remains within the VA, and additional work entailed basically 
by sending somebody out. And so that will need to be moved into 
our work stream. So I think your solution is a good first step. 
It may take still more.
    Senator Moran. I would--I don't know that this was in your 
purview, but I would refer the VA back to the ARCH program. It 
was the pilot program that predated Choice in I think four 
locations across the country. There were pilot programs to 
demonstrate how community care could or should work, and in 
those instances, there was someone within the VA who monitored 
the care for those veterans in the ARCH program, and it--my 
experience is only with the one pilot program in Kansas. If the 
Senator from Maine was here, she would be talking about the 
value of that program in Maine. I would just refer the VA to 
look at how that was done. The data and information gained from 
that pilot program, in my view, could help determine what that 
program should look like in a broader sense.
    Dr. Meyer. This is a program at scale. This now represents 
about 30 percent of all of our care, so this is a lot more than 
one coordinator. This has to be a system.
    Senator Moran. Understood.
    I always try to give the witnesses an opportunity to inform 
the subcommittee of anything that they wish they would have 
said or regret saying.
    [Laughter.]
    Senator Moran. If you have anything you would like to add 
for the record, clarify for the record, we'd be glad to hear 
from any of you before I conclude the hearing.
    Mr. Missal. I would just like to thank you for holding this 
hearing. Even though our report is relatively limited in terms 
of our just focus on opioids, our hope is that it has messages 
that are broader. We put out reports so it gets attention. 
Holding hearings like this get attention. And we think this 
will have a great benefit going forward.
    Senator Moran. Mr. Missal, I've suggested, at least to 
myself, that you and I have a regular meeting in which you tell 
me what you're looking at and what you're finding, and while I 
told myself I haven't accomplished that yet, and I look forward 
to a greater regularity of which we utilize the information 
that you garner, and perhaps you utilize our ability to 
highlight those recommendations and help us monitor to make 
certain that those recommendations that are agreed to by the VA 
are actually implemented.
    Mr. Missal. I'm happy to do so.
    Senator Moran. Thank you.
    Dr. Meyer. And I would add my thanks to you for holding the 
hearing, and also to Jason's family, the Simcakoskis, for their 
continued work on this and advocacy, and to Senators Baldwin 
and Capito for getting us rolling with CARA and keeping us 
moving on that.
    Senator Moran. Mr. Simcakoski, thank you very much, Doctor 
you mentioned the bipartisan nature and your goal of seeing 
whether government actually works. And all of us at this table 
and those that were here earlier, we wish this process worked 
better, we wish there was more bipartisanship, we wish we were 
locking arms and solving problems. There are always going to be 
differences of how we do it, that's not the issue here, but the 
goodwill desire to see that there's a result rather than score 
political points, and I'm often--your circumstance highlights 
the importance of this.
    My walk down to the Vietnam Wall or the Lincoln Memorial 
and go by the World War II Memorial or the Korean War Memorial 
reminds me of the sacrifice that so many people made had 
nothing to do with Democrats or Republicans, and we need to 
roll-model ourselves after your son and his service and those 
who served with him, the calling that they had, which is 
sometimes seemingly so different than the calling we seem to 
think we have.
    And so I hope at the end of my time in public service that 
there's a little bit less cynicism about the way this process 
is. And I think all of us here want to contribute to reducing 
the cynicism and proving to you that the American government is 
still something that matters to the American people. So thank 
you.
    Mr. Simcakoski. All right. Thank you all also.

                     ADDITIONAL COMMITTEE QUESTIONS

    Senator Moran. I do want to reiterate the need for the 
Department to stay on top of this issue, to continue to monitor 
the prescribing process, remain innovative in your responses, 
to make sure that we do everything to reduce opioid use. We owe 
that to the men and women who serve our country. Thank you for 
your service at the Department of Veterans Affairs, and we look 
forward to good things happening for all veterans.
    I again thank our witnesses for being here. I would remind 
the subcommittee members that if they have any questions that 
haven't been asked today, they can submit them for the record. 
They should be turned in to the subcommittee staff no later 
than Wednesday, November 22nd. That way you won't have to spend 
Thanksgiving preparing those questions, or your staffs will 
not.
             Question Submitted to Dr. Friedhelm Sandbrink
             Question Submitted by Senator Susan M. Collins
    Question. In 2014, I worked to ensure that our service members and 
veterans could participate in safe prescription drug disposal programs 
throughout the Department of Defense and VA. This effort provides 
veterans a reliable, safe, accessible, and accountable method to 
dispose of unneeded medications while reducing the risk of overdose, 
misuse, or diversion. Could you provide the committee with an update on 
VA's drug take back programs and their impact on combating opioid 
abuse?
    Answer. Veterans Health Administration (VHA) appreciates Senator 
Collins' efforts to ensure Veterans' needs were addressed when the Drug 
Enforcement Administration (DEA) published the Final Rule on Disposal 
of Controlled Substances. It is VHA policy that each Department of 
Veterans Affairs (VA) medical facility (including associated VA 
community clinics) must implement at least one practical, accessible, 
and secure option for patient disposal of controlled substances 
medications when appropriate and in applicable settings. All VHA 
facilities have mail back envelopes for distribution to Veterans free 
of charge. In addition, over 100 facilities have on-site receptacles 
that Veterans may use to dispose of their unwanted/unneeded 
medications. As of September 30, 2017, Veterans have returned over 
107,000 pounds (53 tons) of unwanted/unneeded medication using these 
services. Removal of this medication from Veterans' homes reduces the 
risk of diversion as well as intentional and unintentional overdoses 
and poisonings. All returned medications are destroyed in an 
environmentally responsible manner and in compliance with all DEA 
regulations through the use of a third-party vendor. Information on 
these services for Veterans, as well as medication safety in the home, 
is posted on the VA website at: https://www.pbm.va.gov/
vacenterformedicationsafety/
vacenterformedicationsafetyprescriptionsafety.asp. In addition, VHA 
partnered with the Department of Defense to produce a public safety 
announcement on this important topic. It is hosted on YouTube at: 
https://www.youtube.com/watch?v=77-ZbwhVm4s.

                          SUBCOMMITTEE RECESS

    Senator Moran. And I also want to take this opportunity--
this probably is our last hearing for the calendar year of 
2017. I'm sorry, the calendar year of 2017. I appreciate the 
relationship and cooperation with Senator Schatz. And I 
particularly want to thank both our minority and majority 
staff. We've had eight hearings this year. It's work. Most of 
the burden falls upon the people behind me. And I'm very 
grateful for their commitment to see that good things happen 
both in our military as well as our veteran--Department of 
Veterans Affairs, and serve those who need our help within the 
military, and those who need our help within the veteran 
community.
    And with that, I conclude the hearing. Thank you.
    [Whereupon, at 4:30 p.m., Wednesday, November 15, the 
subcommittee was recessed, to reconvene subject to the call of 
the Chair.]

                                   [all]