[Senate Hearing 115-634]
[From the U.S. Government Publishing Office]
S. Hrg. 115-634
VA EFFORTS TO PREVENT AND COMBAT OPIOID OVERMEDICATION
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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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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
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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
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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
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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.
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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.
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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\
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\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.
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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.
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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\
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\4\ Section 3.3, p. 21, citing https://www.ahrq.gov/professionals/
preventionchroniccare/improve/coordination/index.html. Accessed
September 22, 2015.
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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.]
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