STATEMENT OF
ANTONETTE ZEISS, PH.D.
ASSOCIATE CHIEF CONSULTANT, OFFICE OF MENTAL HEALTH SERVICES
VETERANS HEALTH ADMINISTRATION
DEPARTMENT OF VETERANS AFFAIRS
COMMITTEE ON VETERANS' AFFAIRS
SUBCOMMITTEE ON HEALTH

March 11, 2008

Mr. Chairman and members of the Subcommittee, I am pleased to be here today to discuss the ongoing steps that the Department of Veterans Affairs ( VA) is taking to treat substance abuse and co-morbid disorders. I am accompanied by Mr. Charles Flora, Executive Assistant of Readjustment Counseling Service. Mr. Flora is a clinical social worker and Vietnam veteran, and has a lifetime of experience in readjustment counseling at both the Vet Center and national levels.

Also accompanying me is Dr. John Allen, Associate Chief Consultant for Addictive Disorders. Dr. Allen is a national expert on substance use disorders and is a veteran of Operation Iraqi Freedom. His commitment to this work goes beyond the call of a doctor-patient relationship and echoes the pledge our service members make to one another. While VA has always taken the problem of substance use disorder ( SUD) very seriously and has demonstrated our commitment to helping our veterans overcome this disease, we welcome Dr. Allen's personal connection to our returning veterans.

We thank the Committee and you, Chairman Michaud, for your active interest in this topic. Tragically, substance use disorders are common in our society, as they are in many societies. As all of you know, the incidence of substance use among veterans tends to exceed that of comparable civilian populations. One study by Todd Wagner, et al from 2007 found veterans are more likely than non-veterans to report driving under the influence of alcohol, smoking daily, and using marijuana. In another study, by Dr. Charles Hoge and published in the New England Journal of Medicine in 2004, the number of respondents who admitted to using alcohol more than they intended increased seven percent among Army respondents after deployment to Iraq or Afghanistan. Alcohol and drug misuse are associated with a host of medical, social, mental health, and employment problems. Fortunately, these problems are treatable, and with treatment, the lives of our patients and their loved ones can be enriched.

Since the implementation of the Mental Health Strategic Plan, VHA has dedicated more than $458 million to improve access and quality of care for veterans who present with SUD treatment needs. We have authorized the establishment of 510 new substance use counselors and plan to continue expanding SUD services throughout Fiscal Year 2008 (FY 2008) and FY 2009. In FY 2008, for example, our mental health enhancement budget includes over $37.5 million for expanded SUD services. VA is developing plans to allocate medical care funds from the FY 2008 funding to hire even more new professionals, develop new programs, expand existing services, and create an appropriate physical environment for care by upgrading the safety and physical structure of inpatient psychiatry wards, as well as domiciliary and residential rehabilitation programs.

VA has increased the number of intensive outpatient SUD programs and plans further expansion. This reflects the continued transition from inpatient care to more effective intensive outpatient care for treating substance abuse problems. These efforts will increase access to substance abuse services throughout VA.

Whenever a veteran is seen by a VA provider, he or she is screened for PTSD, military sexual trauma, depression, and problem drinking. We recognize screening is only valuable if we act upon positive screens and follow-up in a timely manner, and we are committed to doing that.

For those needing additional services, VA's outpatient and inpatient SUD programs are available; there are more than 220 programs in place, with more in development. Detoxification services may be offered in inpatient units such as medicine, psychiatry, or inpatient chemical dependency units, but the majority of patients requiring detoxification are managed on an outpatient or ambulatory basis. Following detoxification, substance use disorder patients are generally seen in outpatient specialty clinics. VA maintains extended care facilities, including 19 inpatient programs designed specifically to treat SUD patients for 14 to 28 days. Additionally, there are 44 SUD residential rehabilitation treatment facilities, 15 SUD compensated work therapy programs, and 19 SUD focused domiciliaries. We also offer mental health intensive case management, where teams of VA health care providers visit patients in their own living arrangements.

Most SUD patients are treated once or twice a week in outpatient clinics, while others may require more intensive outpatient care for a minimum of four hours per day. Thirty-four of the intensive outpatient facilities have the capability of offering treatment five days a week, and telemedicine services are offered to patients living in remote sites. Veterans with serious mental illness in addition to SUD, are seen in specialized programs, such as intensive outpatient substance use disorder clinics, mental health intensive case management, psychosocial rehabilitation and recovery day programs, and work programs.

Common elements of treatment for SUD include FDA-approved medications, employment of cognitive-behavioral therapies, incorporation of peer support groups (such as Alcoholics Anonymous), enlistment of the support of significant others, and linking the veteran to community services.

Mental health care, including attention to SUD, is being integrated into primary care clinics, and we also are integrating mental health services into VA's Community Based Outpatient Clinics ( CBOCs), VA nursing homes, and residential care facilities. Placing mental health providers in the context of primary care for the veteran is essential; it recognizes the interrelationships of mental and physical health, as well as providing mental health care at the most convenient and desirable location for the veteran.

VA has allocated $57.6M over the last three years to expand the capacity of our Domiciliary and Residential Rehabilitation Treatment (( DRRT)) bed programs. This expansion relieves pressure on acute psychiatric and SUD beds, but more importantly, these Residential Rehabilitation programs provide a therapeutic placement for recovering patients in a longer-term rehabilitation setting. They offer intensive therapy experiences, well beyond what is offered in acute inpatient programs, and thus are a more appropriate level of care for the veteran. VA funded eleven new ( DRRT) programs between FY 2005 and FY 2007, and during that same period, enhanced staffing for specialized services, like SUD treatment, in fifteen others.

VA employs full and part time psychiatrists and full and part time psychologists who work in collaboration with social workers, mental health nurses, counselors, rehabilitation specialists, and other clinicians to provide a full continuum of mental health services for veterans. We have steadily increased the number of these mental health professionals over the last two and a half years. Currently, we have hired over 3,800 new mental health staff in that time period, for a total mental health staff of over 16,500. Appropriate attention to the physical and mental health needs of veterans will have a positive impact on their successful re-integration into civilian life.

In addition to the care offered in medical facilities and CBOCs, VA's Vet Centers provide outreach and readjustment counseling services to returning war veterans of all eras. It is well-established that rehabilitation for war-related PTSD, SUD, and other military-related readjustment problems, along with the treatment of the physical wounds of war, is central to VA's continuum of health care programs specific to the needs of war veterans. The Vet Center service mission goes beyond medical care in providing a holistic mix of services designed to treat the veteran as a whole person in his/her community setting. Vet Centers provide an alternative to traditional mental health care that helps many combat veterans overcome the stigma and fear related to accessing professional assistance for military-related problems. Vet Centers are staffed by interdisciplinary teams that include psychologists, nurses and social workers, many of whom are veteran peers.

Vet Centers provide professional readjustment counseling for war-related psychological readjustment problems, including PTSD counseling. Other readjustment problems may include family relationship problems, lack of adequate employment, lack of educational achievement, social alienation and lack of career goals, homelessness and lack of adequate resources, and other psychological problems such as depression and/or SUD. Vet Centers also provide military-related sexual trauma counseling, bereavement counseling, employment counseling and job referrals, preventive health care information, and referrals to other VA and non- VA medical and benefits facilities.

VA is currently expanding the number of its Vet Centers. In February 2007, VA announced plans to establish 23 new Vet Centers increasing the number nationally from 209 to 232. This expansion began in 2007 and is planned for completion in 2008. Fifteen of the new Vet Centers have hired staff and are fully open. Five Vet Centers have hired staff and are providing client services, but are operating out of temporary space while they finalize their lease contracts. The three remaining Vet Centers are actively pursuing and/or completing staff recruiting and lease contracting. They will all be open by the end of the fiscal year.

To enhance access to care for veterans in underserved areas, some Vet Centers have established telehealth linkages with VA medical centers that extend VA mental health service delivery to remote areas to underserved veteran populations, including Native Americans on reservations at some sites. Vet Centers also offer telehealth services to expand the reach to an even broader audience. Vet Centers address veterans' psychological and social readjustment problems in convenient, easy-to-access community-based locations and generally support ongoing enhancements under the VA Mental Health Strategic Plan.

Since hostilities began in Afghanistan and Iraq, the focus of the Vet Center program has been on aggressive outreach at military demobilization and at National Guard and Reserve sites, as well as at other community locations that feature high concentrations of veterans and family members. To promote early intervention, the Vet Center program hired 100 OEF and OIF veteran returnees to provide outreach services to their fellow combatants. These fellow veteran outreach specialists are effective in mitigating veterans' fear and stigma associated with seeking professional counseling services. From early in FY 2003 through the end of FY 2007, Vet Centers have provided readjustment services to over 268,987 veteran returnees from OEF and OIF. Of this total, more than 205,481 veterans were provided outreach services, and 63,506 were provided substantive clinical readjustment services in Vet Centers.

VA's research program also demonstrates our commitment to providing the best care possible for veterans with substance use disorders. The VA Office of Research and Development ( ORD) directly funds approximately 100 active research studies of addictive disorders, including basic biological mechanisms of dependence, abuse and relapse, as well as genetics of alcoholism, treatments of alcoholism, drug abuse, and nicotine addiction. Many of VA's most eminent scientists, including a large cadre of VA Research Career scientists and our 2004 Middleton Awardee ( VA's highest honor for medical research), are devoting their careers to further understanding and treating substance use disorders in the veteran population. ORD is also working closely with the National Institutes of Health, specifically the National Institute of Mental Health and the National Institute of Drug Abuse, to forge research collaborations on substance abuse co-morbidities with mental illness, such as PTSD.

Substance use disorder is a real problem, and its manifestation along with other mental health conditions can lead to physical health concerns, difficulty readjusting to civilian life, and a host of other problems. One of VA's highest priorities is to reduce the impact of substance abuse and provide veterans with the care they need. Thank you for your time and for the opportunity to discuss this important issue with you. I would be happy to address any questions you may have.