VA Faces Challenges in Providing Substance Use Disorder Services and Is Taking Steps to Improve These Services for Veterans
Gao ID: GAO-10-294R March 10, 2010Substance use disorders (SUD), such as alcohol abuse and drug addiction, are serious health conditions that affect many Americans, including a substantial number of veterans. According to the Department of Veterans Affairs (VA), about 420,000 of the over 5 million veterans receiving health care from VA had SUD diagnoses in fiscal year 2009. Both older veterans and veterans of the current military operations in Iraq and Afghanistan are at risk for SUDs, as veterans may use drugs or alcohol to help cope with the effects of stressful events experienced during deployment or with difficulties they encounter in readjusting from wartime military service to civilian life. The identification and treatment of veterans with SUDs is important, as SUDs can have harmful effects on veterans' physical, psychological, and social well-being if left untreated. VA provides SUD services in a range of settings, including inpatient SUD programs that provide acute in-hospital care, which may include detoxification services; residential rehabilitation treatment programs, which provide intensive treatment and rehabilitation services with supported housing; intensive outpatient programs, which provide at least 3 hours of treatment services 3 days per week; and standard outpatient programs, which provide less-intensive outpatient services. This report provides an overview of: (1) the challenges that VA officials and providers reported facing in their efforts to provide SUD services to veterans who have or are at risk for SUDs; and (2) the national efforts VA has recently undertaken to improve its SUD services for veterans who have or are at risk for SUDs.
VA officials and providers reported facing challenges related to providing SUD services to veterans who have or are at risk for SUDs in three areas--providing access to SUD services, meeting the specific treatment needs of veterans with SUDs, and assessing the effectiveness of SUD treatments. These reported challenges include the following: (1) Challenges related to access to SUD services--Several VA medical centers have faced challenges hiring additional SUD staff to meet veterans' needs for SUD services. In addition, it can be difficult for veterans to access VA residential programs because beds in those programs may not always be immediately available. (2) Challenges related to meeting the specific treatment needs of veterans with SUDs--VA faces challenges increasing the use of pharmacotherapies5 that can assist veterans with SUD recovery. According to VA officials, certain pharmacotherapies are underutilized by VA providers for reasons that could include providers' lack of awareness of or training on pharmacotherapies and reluctance among providers to use them. Implementing additional psychotherapies can also be challenging because training can be time-intensive for both providers and trainers. (3) Challenges related to assessing the effectiveness of SUD treatments--VA officials and providers noted factors that can make it difficult to assess the effectiveness of VA SUD treatments, including a lack of information about veterans after they are discharged from treatment and standardized measures for assessing treatment outcomes. To improve its SUD services, VA has recently begun a number of national efforts, including increasing access to SUD services, promoting evidence-based treatments for SUDs, and assessing SUD services and monitoring treatment effectiveness. According to VA officials, these efforts may address multiple challenges that VA faces in providing SUD services. VA's efforts include the following: (1) Efforts to increase veterans' access to its SUD services--VA is in the process of establishing additional intensive outpatient programs at VA facilities. VA is also hiring SUD specialists to work in non-SUD settings, including non-SUD residential rehabilitation treatment programs and community-based outpatient clinics. (2) Efforts to promote the use of evidence-based SUD treatments--VA is requiring facilities to make certain evidence-based SUD treatments, such as cognitive behavioral therapy for relapse prevention, available to veterans. In addition, VA has implemented training for physicians on the use of pharmacotherapies as part of veterans' SUD treatment. (3) Efforts to assess SUD services and monitor treatment effectiveness--VA is assessing the progress that VA medical centers are making toward implementing the requirements listed in the Handbook related to SUD services. VA is also testing a new data collection tool--the Brief Addiction Monitor--that could be used to monitor treatment effectiveness at the individual patient and VA medical center levels.
GAO-10-294R, VA Faces Challenges in Providing Substance Use Disorder Services and Is Taking Steps to Improve These Services for Veterans
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GAO-10-294R:
United States Government Accountability Office:
Washington, DC 20548:
March 10, 2010:
The Honorable Michael H. Michaud:
Chairman:
Subcommittee on Health:
Committee on Veterans' Affairs:
House of Representatives:
The Honorable Brian Baird:
House of Representatives:
Subject: VA Faces Challenges in Providing Substance Use Disorder
Services and Is Taking Steps to Improve These Services for Veterans:
Substance use disorders (SUD), such as alcohol abuse and drug
addiction, are serious health conditions that affect many Americans,
including a substantial number of veterans. According to the
Department of Veterans Affairs (VA), about 420,000 of the over 5
million veterans receiving health care from VA had SUD diagnoses in
fiscal year 2009.[Footnote 1] Both older veterans and veterans of the
current military operations in Iraq and Afghanistan are at risk for
SUDs, as veterans may use drugs or alcohol to help cope with the
effects of stressful events experienced during deployment or with
difficulties they encounter in readjusting from wartime military
service to civilian life.
The identification and treatment of veterans with SUDs is important,
as SUDs can have harmful effects on veterans' physical, psychological,
and social well-being if left untreated. For example, substance use
has been shown to be a primary risk factor for both homelessness and
suicide among veterans. It is also important to identify and counsel
veterans who may not meet the diagnostic criteria for an SUD--that is,
they may not abuse or be dependent on alcohol or drugs--but use
substances to a degree that puts them at risk for developing an SUD or
other health problems.
VA provides SUD services in a range of settings, including inpatient
SUD programs that provide acute in-hospital care, which may include
detoxification services; residential rehabilitation treatment
programs, which provide intensive treatment and rehabilitation
services with supported housing; intensive outpatient programs, which
provide at least 3 hours of treatment services 3 days per week; and
standard outpatient programs, which provide less-intensive outpatient
services. VA also provides SUD-related care in non-SUD settings,
including primary care clinics and non-SUD residential rehabilitation
treatment programs.
VA's services for veterans with SUDs have been evolving in recent
years, and VA is currently in the process of implementing a number of
changes to its SUD services. VA's 2004 mental health strategic plan
noted that its system of SUD services had been in decline since the
mid-1990s and that VA needed to improve its access to care for
veterans with SUDs.[Footnote 2] Since then, VA has taken steps to
enhance its SUD services. For example, in September 2008, VA finalized
its Uniform Mental Health Services Handbook (Handbook), which lists
the mental health services--including SUD services--that must be
provided or made available to veterans by VA medical centers and
clinics.[Footnote 3]
You asked us to review VA's provision of SUD services. This report
provides an overview of:
1. the challenges that VA officials and providers reported facing in
their efforts to provide SUD services to veterans who have or are at
risk for SUDs, and:
2. the national efforts VA has recently undertaken to improve its SUD
services for veterans who have or are at risk for SUDs.
To conduct this work, we reviewed VA guidance, reports, and other
documents about VA's SUD services and related efforts. We also
interviewed VA officials with responsibilities related to SUDs, mental
health, primary care, pain management, and performance management.
These included VA officials from groups that are involved with VA SUD
areas such as policy, training, evaluation, and the translation of
research into clinical practice: the two VA Centers of Excellence for
Substance Abuse Treatment and Education, VA's Program Evaluation and
Resource Center, and VA's SUD Quality Enhancement Research Initiative.
In addition, we conducted interviews with SUD, mental health, and
primary care staff from four VA medical centers--located in Beckley,
West Virginia; Martinsburg, West Virginia; Philadelphia, Pennsylvania;
and Prescott, Arizona--to discuss SUD services and challenges in
providing care. This judgmental sample was chosen in order to include
VA medical centers that varied in terms of (1) the range of SUD
services offered, (2) facility size,[Footnote 4] and (3) regional
location. We also interviewed staff at a residential rehabilitation
treatment program located in Coatesville, Pennsylvania, where the VA
medical center in Philadelphia refers veterans for residential care.
Further, we reviewed data that VA uses to monitor several of its SUD
services. To assess the reliability of these data, we reviewed
relevant documentation and interviewed agency officials knowledgeable
about the data and the methodologies used to collect them. We
determined that the data were sufficiently reliable for the purposes
of this report.
We reviewed VA's national efforts to improve SUD services that were
identified for us by VA headquarters officials. We did not conduct a
comprehensive review of all VA programs, research, or other activities
that relate to VA's provision of SUD services or of all the challenges
VA faces in providing SUD services. We also did not review VA's
challenges or efforts related to nicotine use. In addition, the
findings from our interviews cannot be generalized to other VA medical
centers.
We conducted our work from March 2009 to February 2010 in accordance
with all sections of GAO's Quality Assurance Framework. The framework
requires that we plan and perform the engagement to obtain sufficient
and appropriate evidence to meet our stated objectives and to discuss
any limitations in our work. We believe that the information and data
obtained, and the analysis conducted, provide a reasonable basis for
any findings and conclusions.
Summary of Findings:
VA officials and providers reported facing challenges related to
providing SUD services to veterans who have or are at risk for SUDs in
three areas--providing access to SUD services, meeting the specific
treatment needs of veterans with SUDs, and assessing the effectiveness
of SUD treatments. These reported challenges include the following:
* Challenges related to access to SUD services--Several VA medical
centers have faced challenges hiring additional SUD staff to meet
veterans' needs for SUD services. In addition, it can be difficult for
veterans to access VA residential programs because beds in those
programs may not always be immediately available.
* Challenges related to meeting the specific treatment needs of
veterans with SUDs--VA faces challenges increasing the use of
pharmacotherapies[Footnote 5] that can assist veterans with SUD
recovery. According to VA officials, certain pharmacotherapies are
underutilized by VA providers for reasons that could include
providers' lack of awareness of or training on pharmacotherapies and
reluctance among providers to use them. Implementing additional
psychotherapies[Footnote 6] can also be challenging because training
can be time-intensive for both providers and trainers.
* Challenges related to assessing the effectiveness of SUD treatments--
VA officials and providers noted factors that can make it difficult to
assess the effectiveness of VA SUD treatments, including a lack of
information about veterans after they are discharged from treatment
and standardized measures for assessing treatment outcomes.
To improve its SUD services, VA has recently begun a number of
national efforts, including increasing access to SUD services,
promoting evidence-based[Footnote 7] treatments for SUDs, and
assessing SUD services and monitoring treatment effectiveness.
According to VA officials, these efforts may address multiple
challenges that VA faces in providing SUD services. VA's efforts
include the following:
* Efforts to increase veterans' access to its SUD services--VA is in
the process of establishing additional intensive outpatient programs
at VA facilities. VA is also hiring SUD specialists to work in non-SUD
settings, including non-SUD residential rehabilitation treatment
programs and community-based outpatient clinics.
* Efforts to promote the use of evidence-based SUD treatments--VA is
requiring facilities to make certain evidence-based SUD treatments,
such as cognitive behavioral therapy for relapse prevention, available
to veterans. In addition, VA has implemented training for physicians
on the use of pharmacotherapies as part of veterans' SUD treatment.
* Efforts to assess SUD services and monitor treatment effectiveness--
VA is assessing the progress that VA medical centers are making toward
implementing the requirements listed in the Handbook related to SUD
services. VA is also testing a new data collection tool--the Brief
Addiction Monitor--that could be used to monitor treatment
effectiveness at the individual patient and VA medical center levels.
Concluding Observations:
As it rebuilds its system of SUD services, VA reports facing
challenges that span the entire course of SUD treatment--from
identifying and engaging veterans who need treatment to tracking
patient outcomes after treatment. While VA has undertaken a number of
efforts to improve its SUD services, VA's efforts in this area are
still evolving, and VA has not yet fully implemented many efforts that
are currently under way. VA's completion of these efforts and
monitoring of its SUD programs and the effectiveness of SUD treatments
are important to ensuring that VA is meeting the needs of the many
veterans with SUDs.
Agency Comments:
We provided a draft of this report to VA for comment. VA reviewed the
draft report and had no comments.
We briefed your staff on the information contained in this report on
February 2, 2010. As discussed with your staff at that time, we agreed
to issue this report, which formally transmits the briefing slides and
updates the information provided at the briefing. (See enclosure I.)
We are sending copies of this report to the Secretary of Veterans
Affairs and appropriate congressional committees. The report also is
available at no charge on GAO's Web site at [hyperlink,
http://www.gao.gov].
If you or your staff have any questions or need additional
information, please contact me at (202) 512-7114 or
williamsonr@gao.gov. Contact points for our Offices of Congressional
Relations and Public Affairs may be found on the last page of this
report. GAO staff members who made key contributions to this report
are listed in enclosure II.
Signed by:
Randall B. Williamson:
Director, Health Care:
Enclosures - 2:
[End of section]
Enclosure I:
VA Faces Challenges in Providing Substance Use Disorder Services and
Is Taking Steps to Improve These Services for Veterans:
Briefing for the Staff of:
The Honorable Michael H. Michaud:
Chairman, Subcommittee on Health:
Committee on Veterans‘ Affairs:
House of Representatives:
The Honorable Brian Baird:
House of Representatives:
Briefing Overview:
* Introduction;
* Objectives;
* Scope and Methodology;
* Background;
* Findings.
Introduction:
Substance use disorders (SUD), such as alcohol abuse and drug
addiction, are serious health conditions that affect many Americans,
including a substantial number of veterans who receive care from the
Department of Veterans Affairs (VA). SUDs are a concern for both older
veterans and veterans of the current operations in Iraq and
Afghanistan. According to VA, about 420,000 of the over 5 million
veterans receiving care at VA had SUD diagnoses in fiscal year 2009.[A]
Identification and treatment of veterans with SUDs is important,as
SUDs can have harmful effects on veterans‘ physical, psychological,
and social well-being. For example, substance use is a primary risk
factor for both homelessness and suicide among veterans.
It is also important to identify and counsel veterans who may not meet
the diagnostic criteria for an SUD”that is, they may not abuse or be
dependent on alcohol or drugs”but use substances to a degree that puts
them at risk for developing an SUD or other health problems.
VA‘s SUD treatment services have been evolving in recent years. VA‘s
2004 mental health strategic plan[B] noted that its system of SUD
services had been in decline since the mid-1990s and that VA needed to
improve access to care for veterans with SUDs. Since then, VA has
taken steps to enhance its SUD services.
[A] The number of veterans with SUD diagnoses does not reflect
veterans who are only dependent on nicotine or who only get care in
VA‘s Vet Centers.
[B] The plan is known formally as A Comprehensive Veterans Health
Administration Strategic Plan for Mental Health Services.
Objectives:
You asked us to review VA‘s provision of SUD services. This briefing
provides an overview of:
* The challenges that VA officials and providers reported facing in
their efforts to provide SUD services to veterans who have or are at
risk for SUDs.
* The national efforts VA has recently undertaken to improve its SUD
services for veterans who have or are at risk for SUDs.
Scope and Methodology:
To accomplish these objectives, we:
* Reviewed documents, such as VA handbooks about mental health,
including SUD services; SUD clinical practice guidelines; VA memoranda
about SUD services and related efforts; and VA‘s 2004 mental health
strategic plan.
* Interviewed VA officials with responsibilities related to SUDs,
mental health, primary care, pain management, and performance
management.
* Conducted interviews with SUD, mental health, and primary care staff
from a judgmental sample of four VA medical centers-”located in
Beckley, West Virginia; Martinsburg, West Virginia; Philadelphia,
Pennsylvania; and Prescott, Arizona-”to discuss SUD services and
challenges in providing care. We also interviewed staff with a
residential rehabilitation treatment program at the VA medical center
in Coatesville, Pennsylvania, where the VA medical center in
Philadelphia refers veterans for residential care.
* Reviewed data VA uses to monitor several of its SUD services. To
assess the reliability of these data, we reviewed relevant
documentation and interviewed agency officials knowledgeable about the
data and the methodologies used to collect them. We determined that
the data were sufficiently reliable for the purposes of this report.
* Reviewed recent VA national efforts to improve SUD services that
were identified for us by VA headquarters officials.
* We did not conduct a comprehensive review of all VA programs,
research, or other activities that relate to VA‘s provision of SUD
services or all of the challenges VA faces in providing SUD services.
We also did not review VA‘s challenges or efforts related to nicotine
use.The findings from our interviews cannot be generalized to other VA
medical centers.
Background: Definition of SUD:
Individuals with SUDs either abuse or are dependent on alcohol or
drugs, which can include illicit substances (such as heroin or
cocaine), prescription drugs (such as pain medications), and over-the-
counter drugs.
* Substance abuse is a pattern of substance use leading to clinically
significant impairment or distress, such as the failure to fulfill
major obligations at work or home, or persistent or recurrent social
or interpersonal problems.
* Substance dependence refers to physiological or psychological
dependence on a substance and can involve a persistent desire for
substance use, an experience of withdrawal symptoms in the absence of
the substance, and a development of tolerance for the substance.
SUDs are considered treatable diseases of the brain. Brain imaging
studies show physical changes in areas of the brain that are critical
to judgment, decision making, learning and memory, and behavior
control. Individuals may have a compulsion to use substances despite
adverse consequences.
Background: Characteristics of SUDs:
SUDs vary in severity and can involve significant disability, physical
risk, and difficulty performing routine activities, such as working
and participation in relationships.
SUDs can be chronic, or recurring, conditions. Individuals who receive
treatment for an SUD may greatly decrease or cease their substance use
over time, but may relapse”-that is, return to active substance use”
before they have achieved stable sobriety. Some individuals may see
early success with treatment but then deteriorate over time, so
alternative approaches may be needed to avoid or manage relapses.
SUDs commonly co-occur with other mental health conditions, such as
depression, and chronic medical illnesses, such as diabetes and heart
disease.
Individuals with an SUD may experience stigma”-that is, negative
labeling or attitudes”regarding their condition.
Background: SUD Treatment:
Treatment can occur in a variety of settings and can take different
forms.
* For example, individuals can receive intensive treatment in
inpatient and specialty care settings or may be seen in primary care
if they are unwilling to seek specialty care or have less severe SUDs.
* Providers treating patients with SUDs vary in how they are educated,
licensed, and certified or credentialed. Also, providers use different
approaches to treat SUDs, such as psychotherapies (behavioral
therapies), which focus on changing individuals‘ behaviors, thoughts,
perceptions, and emotions, and pharmacotherapies, which use
medications to ease detoxification or reduce the urge to use
substances.
Treatment that works for one individual may not work for another, and
how well a treatment works can be related to factors such as whether
the individual has stable housing and employment.
Knowledge gaps remain regarding how best to treat some SUDs, how to
care simultaneously for SUDs and co-occurring conditions, and which
therapies are most effective.
Background: VA‘s Health Care System:
VA‘s health care system is organized into 21 regional health care
networks called Veterans Integrated Service Networks (VISN) that
include VA medical centers and community-based outpatient clinics
(CBOC).
* VA medical centers offer services that range from primary care to
complex specialty care, such as cardiac or spinal cord injury care.
* CBOCs are extensions of VA medical centers and provide primary care
services and other services, such as mental health services.
* In addition, VA provides services through non-VA providers in the
community, such as physicians and hospitals, through contracts or
other arrangements.
Background: VA SUD Services:
VA provides SUD services in a range of SUD-specific settings,
including:
* inpatient SUD programs that provide acute in-hospital care, such as
detoxification services;
* residential rehabilitation treatment programs that provide intensive
treatment and rehabilitation services, with supported housing;
* intensive outpatient programs that provide at least 3 hours of
treatment services 3 days per week; and;
* standard outpatient programs that provide less-intensive outpatient
services.
VA also provides SUD-related care in non-SUD settings, including:
* primary care clinics;
* general mental health clinics;
* programs to treat post-traumatic stress disorder (PTSD);
* non-SUD residential rehabilitation treatment programs, including
PTSD residential programs; and;
* general medical or mental health inpatient units, for detoxification
services.
Background: Veterans with SUDs:
In fiscal year 2009, according to VA:
* Among veterans with SUD diagnoses, about 53 percent had diagnoses of
alcohol-only SUDs, about 21 percent had diagnoses of drug-only SUDs,
and about 26 percent had diagnoses of both alcohol-and drug-related
SUDs.
* Additionally, about 58 percent of veterans with SUD diagnoses also
had a diagnosis of one or more additional mental health conditions.
The most common mental health conditions among veterans diagnosed with
SUDs were PTSD, depression, bipolar disorder, and schizophrenia.
Figure 1: Percentage of Veterans with Substance Use Disorder (SUD)
Diagnoses Who Had Additional Mental Health Conditions in Fiscal Year
2009:
[Refer to PDF for image: horizontal bar graph]
Mental health condition: Post-traumatic stress disorder;
Percentage: 22.6%.
Mental health condition: Depression;
Percentage: 17.7%.
Mental health condition: Bipolar disorder;
Percentage: 7.5%.
Mental health condition: Schizophrenia;
Percentage: 5.0%.
Source: GAO analysis of VA data.
Notes: These percentages are based on the roughly 420,000 veterans who
received care at VA and had SUD diagnoses in fiscal year 2009.
Veterans with SUD diagnoses may have more than one additional mental
health condition.
[End of figure]
Background: VA‘s SUD-Related Screening and Monitoring:
VA policy requires that veterans be screened for alcohol misuse during
their initial visit and at least annually thereafter. VA uses an
evidence-based[A] screening approach, in which veterans are asked
questions about their alcohol consumption, to help identify veterans
who misuse alcohol. According to VA, in fiscal year 2009, about 96
percent of a sample of veterans seen at VA medical centers across the
nation received the recommended screening.
According to VA, it has not implemented similar population-based
screening for drug misuse because such screening is not an evidence-
based approach. Instead, VA policy recommends targeted efforts to
identify veterans who use illicit drugs or misuse prescription or over-
the-counter drugs”for example, by evaluating signs of substance use in
veterans with hepatitis C.
VA monitors whether veterans who enter VA specialty SUD treatment stay
in treatment for at least 90 days, as research has shown that
addiction treatment outcomes depend on the duration of treatment. In
fiscal year 2009, about 52 percent of veterans who entered VA
specialty SUD treatment programs stayed in those programs for at least
90 days.
[A] Approaches that have consistently been shown in controlled
research to be effective for a particular condition or conditions are
referred to as being "evidence-based."
Background: VA‘s Mental Health Strategic Plan and SUDs:
In recent years, VA has focused on enhancing its services for veterans
with SUDs as part of its broader effort to enhance VA‘s overall mental
health services.
* In November 2004, VA approved its mental health strategic plan,
which identified actions and resources needed to address gaps in
mental health services previously identified by VA, including gaps in
services for veterans with SUDs.
* From fiscal year 2005 to fiscal year 2009, VA headquarters allocated
funding to medical centers to implement specific initiatives included
in the mental health strategic plan, including initiatives to expand
VA‘s SUD services.[A]
[A] For additional information about VA‘s mental health strategic
plan, see GAO, VA Health Care: Spending for Mental Health Strategic
Plan Initiatives Was Substantially Less Than Planned, GAO-07-66
(Washington, DC,: November 21, 2006).
Background: Uniform Mental Health Services Handbook and SUDs:
In September 2008, VA finalized Veterans Health Administration
Handbook 1160.01, Uniform Mental Health Services in VA Medical Centers
and Clinics(Handbook).
* The Handbook defines what services must be provided to veterans by
VA medical centers and CBOCs directly and what services must be made
available to veterans by those facilities either through direct care
or referral to VA or non-VA providers.
* According to VA, the Handbook operationalizes the mental health
strategic plan‘s initiatives into requirements for mental health
program areas, including SUDs. When fully implemented, the Handbook‘s
requirements will complete the patient care recommendations included
in the mental health strategic plan.
Challenges in Providing SUD Services: Overview:
Objective 1: What challenges did VA officials and providers report
facing in their efforts to provide SUD services to veterans who have
or are at risk for SUDs?
VA officials and providers reported facing challenges related to
providing SUD services to veterans in three areas:
* providing access to SUD services,
* meeting the specific treatment needs of veterans with SUDs, and
* assessing the effectiveness of SUD treatments.
Challenges: Access to SUD Services Identifying Veterans Who Need
Services:
VA officials and providers reported facing several challenges in
providing veterans access to SUD services:
They noted several factors that can make it difficult for providers in
non-SUD settings to identify veterans who could benefit from accessing
SUD services.
* While VA providers ask veterans an evidence-based set of questions
to identify veterans who misuse alcohol, there is no equivalent set of
evidence-based questions for them to identify veterans who misuse
drugs.
* Some veterans may not admit any substance use or may underreport
their level of substance use.
* Some veterans may not see themselves as having a substance use
problem. For example, some younger veterans may view heavy drinking as
acceptable coping behavior among their peers or may not yet have
experienced significant difficulties with their jobs, families, or
health.
Challenges: Access to SUD Services: Staffing Challenges:
In working to meet veterans‘ needs for SUD services, several VA
medical centers have faced challenges hiring SUD staff.
* Providers at one medical center reported that it took over a year to
find a qualified applicant for an addiction psychiatrist position, and
then the facility could not hire that applicant because of a hiring
freeze.
* Providers at another medical center said that budget concerns had
prevented them from filling SUD positions that became vacant when SUD
staff were moved to fill newly created SUD positions.
* Providers at a rural medical center said that they had difficulties
hiring a psychologist with SUD experience for the medical center‘s
residential rehabilitation treatment program, in part because other
health care facilities were able to offer higher salaries.
* Providers at a VA medical center said that the lengthy hiring
process caused them to lose a qualified applicant for an SUD position.
Challenges: Access to SUD Services: Additional Challenges:
VA providers noted additional challenges related to veterans‘ access
to SUD services.
* It can be difficult for veterans to access VA residential programs
because space is not always available. VA providers said they
sometimes kept patients on an inpatient unit or provided outpatient
services to try to meet veterans‘ needs while they were waiting for
beds to become available at a VA residential program.
* Providers at one VA medical center said they had to refer veterans
to a distant VA residential program because they did not have a
residential program on-site. They noted that this situation was not
ideal because such veterans are removed from their social support
networks and find it difficult to search for work or housing in their
home community.
Challenges: SUD Treatment Needs of Veterans Increasing the Use of
Pharmacotherapies:
VA officials and providers also noted several challenges related to
meeting the specific treatment needs of veterans with SUDs.
VA faces challenges increasing the use of pharmacotherapies to assist
veterans with SUD recovery.[A]
* According to VA officials, certain pharmacotherapies that can help
veterans achieve and maintain sobriety are underutilized by VA
providers. VA officials said that this could be due to factors such as
providers‘ lack of awareness of or training on pharmacotherapies and
reluctance among providers to use them.
* While some providers we spoke with reported prescribing
pharmacotherapies, others stated that they are hesitant to have
veterans with SUDs use them, given the other available treatments.
Providers also said veterans do not often request the
pharmacotherapies or feel they need them.
[A] According to VA policy, pharmacotherapies to treat SUDs should be
used in conjunction with psychotherapy and not as stand-alone
treatment.
Challenges: SUD Treatment Needs of Veterans Implementing Additional
Psychotherapies:
VA officials and providers also noted several challenges related to
implementing additional psychotherapies for SUDs.
* Training for mental health providers can be time-intensive and
involve classroom training, practice of techniques, individual
consultation, and supervision of patient cases.
* It can be difficult to find time and travel funds for staff to
participate in training.
* It can take time for providers to become comfortable with new
practices. Providers may receive training but may not use the new
treatment, may use it for a limited time, or may blend it with another
treatment with which they have more experience.
Challenges: SUD Treatment Needs of Veterans: Treating SUDs and Co-
Occurring Mental Health Conditions:
VA officials and providers reported challenges in treating veterans
with both SUDs and co-occurring mental health conditions, such as PTSD.
* Reaching a diagnosis can be difficult because the same symptom could
be caused by a mental health condition or stem from active substance
use.
* It can be challenging for providers to determine how best to treat
both conditions concurrently.
* Certain pharmacotherapies used to treat mental health conditions may
not be appropriate for veterans with SUDs.
* It can be difficult for providers to manage SUD treatment for
veterans with impaired thinking or cognition due to a mental health
condition because such conditions can affect veterans‘ thoughts about
substance use, their ability to make judgments about substance use,
and their ability to achieve or maintain sobriety.
Challenges: SUD Treatment Needs of Veterans: Treating Veterans in
Primary Care:
VA officials and providers noted several factors that can make it
challenging to meet the treatment needs of veterans with substance use
problems in primary care settings.
* Primary care providers frequently need to address multiple medical
issues during one appointment, which can make it challenging to fully
address SUD issues.
* Primary care providers may need to treat veterans who could benefit
from SUD specialty care but are unwilling to obtain care in specialty
SUD settings.
* Primary care providers vary in terms of their training and
experience treating SUDs.
* Primary care providers can have difficulty finding time for training
on addressing SUD issues.
Challenges: SUD Treatment Needs of Veterans: Additional Challenges:
VA officials and providers noted several additional challenges in
meeting the specific treatment needs of veterans with SUDs.
* It can be challenging to find the most effective approach for re-
engaging veterans who relapse during residential SUD treatment,
according to several VA providers. They noted the need to manage these
situations in a way that gives the veteran an opportunity to receive
care, but does not create the risk of triggering relapses among other
veterans in the same residential SUD treatment program.
* Logistical challenges-”such as a lack of transportation and
difficulties finding local housing for veterans who are homeless or
have unstable home environments-”can complicate retention in SUD
treatment.
* It can be difficult to determine the best way to manage chronic pain
in veterans with a history of substance use because of concerns that
veterans will misuse or become dependent on pain medications. VA
officials noted that such concerns can sometimes be a barrier to
veterans with a history of SUDs receiving effective pain management.
Challenges: Assessing Effectiveness:
In addition, while VA has a range of data on its SUD programs and
patient population, VA officials and providers noted several
challenges that can make it difficult to assess the effectiveness of
VA SUD treatments.[A]
While officials and providers described various indicators that may be
used to monitor veterans‘ progress during treatment, they also noted
factors that can make it difficult to tell how well their programs
work. These factors included:
* a lack of information on veterans after they are discharged from
treatment, in part, because veterans can get follow-up care at other
locations;
* a lack of staff to conduct data analysis; and;
* a lack of standard measures for assessing treatment outcomes and
effectiveness.
Some data limitations make it hard for VA to nationally track and
evaluate certain SUD populations and services. For example, there is
no specific diagnostic code to identify individuals who abuse or are
dependent on prescription drugs.
[A] The effectiveness of treatments can be assessed at a number of
levels, such as the patient, program, or facility levels.
National Efforts to Improve VA‘s SUD Services: Overview:
Objective 2: What national efforts has VA recently undertaken to
improve its SUD services for veterans who have or are at risk for SUDs?
VA has recently undertaken a number of national efforts to improve its
SUD services. According to officials, VA‘s efforts may address
multiple challenges that VA faces in providing SUD services. VA‘s
efforts include efforts to:
* increase access to SUD services,
* promote evidence-based treatments for SUDs, and,
* assess SUD services and monitor treatment effectiveness.
Efforts: Increasing Access to SUD Services: Adding Intensive
Outpatient Programs:
VA has taken steps to increase veterans‘ access to SUD services in
both SUD and non-SUD settings.
VA has begun establishing additional SUD intensive outpatient programs
at selected VA medical centers to make it easier for veterans to
access a level of SUD care that is more intensive than standard
outpatient care.
* VA selected the location of these new programs based on the number
of veterans with SUDs of such severity that treatment provided in a
standard outpatient program would likely be insufficient. VA
established these new programs at locations expected to generate at
least two admissions a week to the program.
* According to VA, these new programs are expected to offer services
such as rehabilitation services, pharmacotherapies to address veterans‘
SUDs, and care for other conditions the veterans may have.
* As of December 2009, 20 of 27 new intensive outpatient programs were
in operation, with the remaining 7 in various stages of
implementation, according to VA.
Efforts: Increasing Access to SUD Services: SUD Specialists in Non-SUD
Settings:
Table 1: VA Substance Use Disorders (SUD) Specialists Added in Non-SUD
Settings:
Non-SUD program setting: Post-traumatic stress disorder (PTSD)
programs at VA medical centers that did not previously provide
integrated treatment for SUDs and PTSD;
Responsibilities of SUD specialists: To more effectively address
concurrent SUDs and PTSD, specialists will provide care for veterans
with dual SUD-PTSD diagnoses and will be responsible for providing
prevention services to other PTSD patients to diminish the risk of
them developing SUDs;
Number of specialists hired as of October 2009: 128 of 146 positions,
all psychologists.
Non-SUD program setting: Non-SUD residential rehabilitation treatment
programs with a caseload of at least 40 veterans;
Responsibilities of SUD specialists: Because veterans in residential
programs often have or have a history of SUDs, specialists will
provide SUD services, including evidence-based treatments, and
facilitate coordination between the residential, general mental
health, and outpatient SUD treatment programs;
Number of specialists hired as of October 2009: 22 of 31 positions,
primarily psychologists.
Non-SUD program setting: Community-based outpatient clinics (CBOC)that
have 5,000 or more patients, are located far away from VA medical
centers, and have historically provided low levels of SUD care;
Responsibilities of SUD specialists: To improve access to SUD services
for veterans that live far from VA medical centers, specialists will
provide SUD services such as individual, group, and family treatment
to veterans with SUDs; evaluations and treatment planning; appropriate
referrals for more intensive treatment; and assistance to primary care
providers;
Number of specialists hired as of October 2009: 32 of 49 positions,
primarily psychologists.
Source: GAO summary of VA information.
[End of table]
Efforts: Increasing Access to SUD Services: VISN SUD Representatives:
VA has recently designated SUD representatives in each VISN to address
a range of SUD issues, including access to SUD services.
* The representatives are expected to address, for example, their VISN‘
s needs related to SUD treatment, including training and supervision
needs; the status of VA medical centers‘ compliance with the SUD
provisions of the Handbook; and the coordination of SUD services
across the VISN.
* According to VA officials, as of August 2009, all 21 VISNs had
selected their SUD representatives.
* In July and August of 2009, VA held two national conferences with
these SUD representatives to discuss the provision of SUD services as
specified in the Handbook and the coordination of SUD care within
VISNs. VA also used these conferences to further define the roles and
responsibilities of the SUD representatives.
Efforts: Increasing Access to SUD Services: Mental Health-Primary Care
Integration:
According to VA officials and providers, another effort that could
improve SUD services for veterans is its broader mental health
initiative to integrate mental health professionals into primary care
settings on a full-time basis.
* VA officials and providers said this effort allows providers to
engage those veterans who are unwilling to seek care in SUD specialty
or general mental health settings, or who have less severe SUDs, by
educating veterans about SUDs and the services available from VA.
* Although there are different models for this integration initiative,
VA‘s Handbook recommends a blended model with mental health
professionals co-located in primary care settings, allowing for ready
consultations on mental health issues, including SUDs.
* The types of mental health professionals serving in primary care
settings as part of this effort include psychologists, psychiatrists,
mental health social workers, and nurses with specialized mental
health training.
Efforts: Promoting Evidence-Based Treatment: Recent Guidance and
Policy Documents:
To help providers meet the specific treatment needs of veterans,VA has
begun a series of efforts to promote the use of evidence-based SUD
treatments.
VA has issued policy and guidance documents to promote the use of
evidence-based treatment in addressing SUDs.
* According to VA officials, the Handbook was designed, in part, to
support VA‘s efforts to provide veterans with SUD services that are
based on scientific evidence. The Handbook requires facilities to make
evidence-based SUD treatments available, including psychotherapies
such as cognitive behavioral therapy for relapse prevention or SUD-
focused family therapy.
* In August 2009, VA and the Department of Defense completed their
update of clinical practice guidelines to assist providers in managing
patients with SUDs.
- VA officials told us that these clinical practice guidelines reflect
validated, evidence-based consensus standards developed by the
National Quality Forum.[A]
- The guidelines include a step-by-step process for recommended
clinical decision making in addressing SUDs, along with a brief
discussion of the research supporting the rationale for those
decisions.
[A] The National Quality Forum is a nonprofit organization focused on
improving quality of care and includes private and public
stakeholders, such as the National Institute on Alcohol Abuse and
Alcoholism and the Substance Abuse and Mental Health Services
Administration.
Efforts: Promoting Evidence-Based Treatment: Promoting Evidence-Based
Pharmacotherapies:
VA officials also reported efforts to promote the increased use of
pharmacotherapies-”in conjunction with psychotherapies”-in managing
withdrawal and detoxification from alcohol or drugs and for SUD
treatments.
* In October 2008, VA required that a minimum of two physicians at
each VA medical center complete Web-based training on improving
medical management of SUDs.
- These two physicians should serve as resources for other VA facility
staff on managing withdrawal and detoxification.
- Training topics included using pharmacotherapies to ease withdrawal
symptoms and for the long-term management of SUDs, such as using the
medication naltrexone as a treatment for alcohol dependence.
* Both the Handbook and the SUD clinical practice guidelines indicate
that providers should consider the use of pharmacotherapies as part of
their overall treatment plan for patients with SUDs. For example, the
Handbook requires that facilities make medications, such as
buprenorphine for treatment of opioid dependence, available to
veterans.
Efforts: Promoting Evidence-Based Treatment: Treating Veterans with
Both SUDs and PTSD:
VA is also working to develop guidance for providers on evidence-based
practices for treating veterans with both SUDs and co-occurring PTSD.
* In October 2009, VA held a 2-day meeting of SUD and PTSD experts to
review evidence regarding treatment for veterans with both SUDs and
PTSD and to discuss how best to treat both conditions concurrently.
* In January 2010, VA reported that it was developing guidance for
providers based on the outcome of this meeting. These recommendations
will help inform providers in treating veterans with SUDs and PTSD.[A]
[A] The Handbook notes that SUDs must not be a barrier for treatment
of patients with other mental health conditions, and also that other
mental health conditions must not be a barrier to treating patients
with SUDs. It also notes that when PTSD or other mental health
conditions co-occur with SUDs, treatment approaches for the other
conditions need to be made available, if not medically
contraindicated, with appropriate coordination of care.
Efforts: Promoting Evidence-Based Treatment: Brief Alcohol Counseling:
In January 2008, VA implemented a computer-based clinical reminder[A]
that prompts primary care and other providers to conduct brief alcohol
counseling for veterans who screen positive when answering VA‘s
questions about alcohol misuse.
* Brief alcohol counseling involves feedback to veterans on the
medical problems associated with alcohol consumption and advice to
either abstain from drinking or to drink within recommended limits.
* Although brief alcohol counseling is an evidence-based practice that
has been shown to decrease drinking and reduce adverse health
outcomes, VA had found that most veterans who screened positive for
alcohol misuse did not have such counseling documented in their
medical records.
* Since 2008, VA has monitored whether brief alcohol counseling takes
place within 2 weeks for veterans who screen positive for alcohol
misuse. According to VA, rates of documented brief counseling have
increased since this clinical reminder was implemented. During fiscal
year 2009, 54 percent of a sample of veterans seen at VA medical
centers across the nation who screened positive for alcohol misuse had
brief alcohol counseling documented in their medical records.
[A] Clinical reminders are alerts in veterans‘ electronic medical
records that remind providers to address specific health issues. VA
uses a number of clinical reminders to alert providers that a veteran
needs to be screened for conditions such as PTSD and traumatic brain
injury.
Efforts: Assessing SUD Services and Effectiveness: Assessing
Implementation of the Handbook:
Finally, VA is taking steps to assess SUD services and monitor the
effectiveness of SUD treatment.
VA is in the early stages of assessing the progress VA medical centers
and CBOCs have made in implementing the Handbook, including its
requirements related to SUD services.
* VA‘s assessment of VA medical centers‘ and CBOCs‘ progress in
implementing the Handbook‘s requirements will use information from
facility self-reports, site visits, and VA‘s administrative databases.
* VA‘s assessment will focus on broad categories, such as processes
and outcomes of care. VA also plans to track new mental health
positions”-including SUD positions-”funded as part of VA‘s mental
health strategic plan initiatives,as well as total mental health
staffing and spending to determine if VA medical centers and CBOCs are
sustaining recent mental health enhancements.
* VA has collected baseline self-reported data from VA medical centers
and CBOCs on the status of their implementation of the Handbook as of
August 31, 2009. VA has also finalized the measures it will use to
evaluate their implementation.
* VA officials said they expected that some VA medical centers and
CBOCs would find it easier than others to meet the Handbook‘s
requirements by October 1, 2009”VA‘s target date for full
implementation. VA plans to provide ongoing assistance to facilities,
as needed, to address any challenges they may have implementing the
Handbook and meeting its requirements.
Efforts: Assessing SUD Services and Effectiveness: Brief Addiction
Monitor:
VA is in the process of testing a new data collection tool-”the Brief
Addiction Monitor (BAM)-”which could be used throughout VA to evaluate
the outcomes and effectiveness of SUD treatments.
* The BAM, developed by VA, is a 17-item tool that asks veterans a
range of questions on topics such as current substance use and the
severity of SUD symptoms as well as veterans‘ participation in
structured activities and interactions with family and friends.
* VA has begun a pilot study in which it is implementing the BAM in
selected intensive outpatient programs.[A] VA officials noted that the
expectation is that these questions will be completed by veterans at
the start of treatment and at a follow-up point, if they are still in
treatment.
* According to VA, this pilot study, which began in August 2009, is
expected to last through December 2010. VA will evaluate the BAM and
its implementation to determine how it should be used nationwide.
* If fully implemented throughout VA, the BAM could be used to assess
treatment outcomes at the patient level and to help modify veterans‘
SUD treatments, if needed. The BAM could also be used to assess
treatment outcomes at the facility level to help evaluate SUD
treatments and systems of care.
[A] In January 2010, VA officials reported that there were 41
intensive outpatient programs participating in the pilot study, with
more programs expected to join the study.
[End of Enclosure I: Briefing Slides]
Enclosure II: GAO Contact and Staff Acknowledgments:
GAO Contact:
Randall B. Williamson, (202) 512-7114 or williamsonr@gao.gov:
Acknowledgments:
In addition to the contact named above, Marcia A. Mann, Assistant
Director; Susannah Bloch; Robin Burke; Cynthia Forbes; and Gay Hee Lee
made key contributions to this report.
[End of Enclosure II]
Footnotes:
[1] The number of veterans with SUD diagnoses does not reflect
veterans who are only dependent on nicotine or who only get care in
VA's Vet Centers, which offer readjustment counseling and other
services for combat veterans.
[2] The plan is known formally as A Comprehensive Veterans Health
Administration Strategic Plan for Mental Health Services.
[3] Veterans Health Administration Handbook 1160.01, Uniform Mental
Health Services in VA Medical Centers and Clinics (Sept. 11, 2008).
[4] VA facilities in our judgmental sample ranged in size from 25 to
145 acute care beds.
[5] Pharmacotherapies use medications to ease detoxification or reduce
the urge to use substances.
[6] Psychotherapies (behavioral therapies) focus on changing
individuals' behaviors, thoughts, perceptions, and emotions.
[7] The term evidence-based refers to approaches that have
consistently been shown in controlled research to be effective for a
particular condition or conditions.
[End of section]
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