GAO-10-294R VA Substance Use Disorder Services 

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 2009.1

 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. 

 

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. 
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 mid1990s and that VA needed to improve its access to care for veterans with SUDs.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.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,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. 

 

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. 

2 GAO-10-294R VA Substance Use Disorder Services
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 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 psychotherapies6

 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-based7

 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. 

 

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. 

3 GAO-10-294R VA Substance Use Disorder Services
• 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 

enc. 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 

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. 

Randall B. Williamson 

Director, Health Care 

Enclosures – 2

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Enclosure I 

5 GAO-10-294R VA Substance Use Disorder Services 

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
Enclosure I 

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2

Briefing Overview

• Introduction

• Objectives

• Scope and Methodology

• Background

• Findings 
Enclosure I 

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3

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.*

• 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** 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.

*

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. **The plan is known formally as A Comprehensive Veterans Health Administration Strategic Plan for Mental Health Services. 
Enclosure I 

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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.
Enclosure I 

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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. 
Enclosure I 

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Scope and Methodology (cont.) 

• 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. 
Enclosure I 

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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. 

o 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.

o 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.
Enclosure I 

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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. 
Enclosure I 

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Background 

SUD Treatment

• Treatment can occur in a variety of settings and can take different forms. 

o 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. 

o 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.
Enclosure I 

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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). 

o VA medical centers offer services that range from primary care to 

complex specialty care, such as cardiac or spinal cord injury care. 

o CBOCs are extensions of VA medical centers and provide primary 

care services and other services, such as mental health services.

o In addition, VA provides services through non-VA providers in the 

community, such as physicians and hospitals, through contracts or 

other arrangements.
Enclosure I 

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Background 

VA SUD Services

• VA provides SUD services in a range of SUD-specific settings, including 

o inpatient SUD programs that provide acute in-hospital care, such as 

detoxification services; 

o residential rehabilitation treatment programs that provide intensive 

treatment and rehabilitation services, with supported housing;

o intensive outpatient programs that provide at least 3 hours of treatment 

services 3 days per week; and 

o standard outpatient programs that provide less-intensive outpatient 

services. 
Enclosure I 

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Background 

VA SUD Services (cont.)

• VA also provides SUD-related care in non-SUD settings, including

o primary care clinics;

o general mental health clinics;

o programs to treat post-traumatic stress disorder (PTSD); 

o non-SUD residential rehabilitation treatment programs, including PTSD 

residential programs; and

o general medical or mental health inpatient units, for detoxification 

services.
Enclosure I 

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Background 

Veterans with SUDs 

• In fiscal year 2009, according to VA:

o 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 drugrelated SUDs.

o 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.
Enclosure I 

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Background 

Veterans with SUDs (cont.)

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.

Figure 1: Percentage of Veterans with Substance Use Disorder (SUD) Diagnoses Who Had Additional Mental Health Conditions in Fiscal Year 2009
Enclosure I 

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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* 

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.

*

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.”
Enclosure I 

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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.

o 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.

o 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.* 

*

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, D.C.: Nov. 21, 2006).
Enclosure I 

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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). 

o 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. 

o 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.
Enclosure I 

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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.
Enclosure I 

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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 nonSUD settings to identify veterans who could benefit from accessing SUD 

services. 

o 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. 

o Some veterans may not admit any substance use or may underreport

their level of substance use. 

o 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. 
Enclosure I 

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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. 

o 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. 

o 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. 

o 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. 

o Providers at a VA medical center said that the lengthy hiring process 

caused them to lose a qualified applicant for an SUD position.
Enclosure I 

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Challenges: Access to SUD Services

Additional Challenges

• VA providers noted additional challenges related to veterans’ access to 

SUD services. 

o 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. 

o 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. 
Enclosure I 

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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.* 

o 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. 

o 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.

*

According to VA policy, pharmacotherapies to treat SUDs should be used in conjunction with psychotherapy and not as stand-alone treatment.
Enclosure I 

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Challenges: SUD Treatment Needs of Veterans 

Implementing Additional Psychotherapies

• VA officials and providers also noted several challenges related to 

implementing additional psychotherapies for SUDs. 

o Training for mental health providers can be time-intensive and involve 

classroom training, practice of techniques, individual consultation, and 

supervision of patient cases. 

o It can be difficult to find time and travel funds for staff to participate in 

training. 

o 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. 
Enclosure I 

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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. 

o Reaching a diagnosis can be difficult because the same symptom 

could be caused by a mental health condition or stem from active

substance use. 

o It can be challenging for providers to determine how best to treat both 

conditions concurrently.

o Certain pharmacotherapies used to treat mental health conditions may 

not be appropriate for veterans with SUDs.

o 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.
Enclosure I 

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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. 

o Primary care providers frequently need to address multiple medical 

issues during one appointment, which can make it challenging to fully 

address SUD issues. 

o 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. 

o Primary care providers vary in terms of their training and experience 

treating SUDs.

o Primary care providers can have difficulty finding time for training on 

addressing SUD issues. 
Enclosure I 

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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.

o It can be challenging to find the most effective approach for reengaging 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.

o 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. 

o 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. 
Enclosure I 

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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.*

• 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

o a lack of information on veterans after they are discharged from treatment, in part, because veterans can get follow-up care at other 

locations; 

o a lack of staff to conduct data analysis; and 

o 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.

*

The effectiveness of treatments can be assessed at a number of levels, such as the patient, program, or facility levels.
Enclosure I 

32 GAO-10-294R VA Substance Use Disorder Services

28

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. 
Enclosure I 

33 GAO-10-294R VA Substance Use Disorder Services

29

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.

o 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.

o 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.

o 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.
Enclosure I 

34 GAO-10-294R VA Substance Use Disorder Services

30

Efforts: Increasing Access to SUD Services

SUD Specialists in Non-SUD Settings

32 of 49 positions, 

primarily psychologists

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.

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

22 of 31 positions, 

primarily psychologists

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.

Non-SUD residential rehabilitation 

treatment programs with a caseload 

of at least 40 veterans

128 of 146 positions, 

all psychologists

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. 

Post-traumatic stress disorder 

(PTSD) programs at VA medical 

centers that did not previously provide 

integrated treatment for SUDs and 

PTSD

Number of 

specialists hired as 

of October 2009

Non-SUD program setting Responsibilities of SUD specialists

Table 1: VA Substance Use Disorders (SUD) Specialists Added in Non-SUD Settings

Source: GAO summary of VA information.
Enclosure I 

35 GAO-10-294R VA Substance Use Disorder Services

31

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. 

o 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.

o According to VA officials, as of August 2009, all 21 VISNs had selected 

their SUD representatives. 

o 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.
Enclosure I 

36 GAO-10-294R VA Substance Use Disorder Services

32

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.

o 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. 

o 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. 

o 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.
Enclosure I 

37 GAO-10-294R VA Substance Use Disorder Services

33

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. 

o 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.

o 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.* 

- 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. 

*

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.
Enclosure I 

38 GAO-10-294R VA Substance Use Disorder Services

34

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. 

o 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. 

o 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. 
Enclosure I 

39 GAO-10-294R VA Substance Use Disorder Services

35

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.

o 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. 

o 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.* 

*

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. 
Enclosure I 

40 GAO-10-294R VA Substance Use Disorder Services

36

Efforts: Promoting Evidence-Based Treatment

Brief Alcohol Counseling

• In January 2008, VA implemented a computer-based clinical reminder* 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. 

o 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. 

o 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.

o 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.

*

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.
Enclosure I 

41 GAO-10-294R VA Substance Use Disorder Services

37

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.

o 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. 

o 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. 

o 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.

o 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. 
Enclosure I 

42 GAO-10-294R VA Substance Use Disorder Services

38

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.

o 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. 

o VA has begun a pilot study in which it is implementing the BAM in selected intensive outpatient programs.* 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.

o 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. 

o 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. 

*

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. 
Enclosure II 

43 GAO-10-294R VA Substance Use Disorder Services 

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. 

(290750) 
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