This is the accessible text file for GAO report number GAO-10-294R entitled 'VA Faces Challenges in Providing Substance Use Disorder Services and Is Taking Steps to Improve These Services for Veterans' which was released on March 10, 2010. This text file was formatted by the U.S. Government Accountability Office (GAO) to be accessible to users with visual impairments, as part of a longer term project to improve GAO products' accessibility. Every attempt has been made to maintain the structural and data integrity of the original printed product. Accessibility features, such as text descriptions of tables, consecutively numbered footnotes placed at the end of the file, and the text of agency comment letters, are provided but may not exactly duplicate the presentation or format of the printed version. The portable document format (PDF) file is an exact electronic replica of the printed version. We welcome your feedback. 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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. 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