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98–642 2016

PRESCRIPTION MISMANAGEMENT AND THE RISK 

OF VETERAN SUICIDE 

HEARING 

BEFORE THE

SUBCOMMITTEE ON OVERSIGHT AND 

INVESTIGATIONS 

OF THE

COMMITTEE ON VETERANS’ AFFAIRS 

U.S. HOUSE OF REPRESENTATIVES 

ONE HUNDRED FOURTEENTH CONGRESS 

FIRST SESSION 

WEDNESDAY, JUNE 10, 2015 

Serial No. 114–25 

Printed for the use of the Committee on Veterans’ Affairs 

( 


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COMMITTEE ON VETERANS’ AFFAIRS 

JEFF MILLER, Florida, Chairman 

DOUG LAMBORN, Colorado 

GUS M. BILIRAKIS, Florida, Vice-Chairman 

DAVID P. ROE, Tennessee 

DAN BENISHEK, Michigan 

TIM HUELSKAMP, Kansas 

MIKE COFFMAN, Colorado 

BRAD R. WENSTRUP, Ohio 

JACKIE WALORSKI, Indiana 

RALPH ABRAHAM, Louisiana 

LEE ZELDIN, New York 

RYAN COSTELLO, Pennsylvania 

AMATA COLEMAN RADEWAGEN, American 

Samoa 

MIKE BOST, Illinois 

CORRINE BROWN, Florida, Ranking 

Minority Member 

MARK TAKANO, California 

JULIA BROWNLEY, California 

DINA TITUS, Nevada 

RAUL RUIZ, California 

ANN M. KUSTER, New Hampshire 

BETO O’ROURKE, Texas 

KATHLEEN RICE, New York 

TIMOTHY J. WALZ, Minnesota 

JERRY MCNERNEY, California 

JON TOWERS, Staff Director 

DON PHILLIPS, Democratic Staff Director 

SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATION 

MIKE COFFMAN, Colorado, Chairman 

DOUG LAMBORN, Colorado 

DAVID P. ROE, Tennessee 

DAN BENISHEK, Michigan 

TIM HUELSKAMP, Kansas 

JACKIE WALORSKI, Indiana 

ANN M. KUSTER, New Hampshire, Ranking 

Member 

BETO O’ROURKE, Texas 

KATHLEEN RICE, New York 

TIMOTHY J. WALZ, Minnesota 

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public hearing records 

of the Committee on Veterans’ Affairs are also published in electronic form. The printed 

hearing record remains the official version. Because electronic submissions are used to prepare 

both printed and electronic versions of the hearing record, the process of converting between 

various electronic formats may introduce unintentional errors or omissions. Such occurrences 

are inherent in the current publication process and should diminish as the process is further 

refined. 


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C O N T E N T S 

Wednesday, June 10, 2015 

Page 

Prescription Mismanagement and the Risk of Veteran Suicide .......................... 1 

OPENING STATEMENTS 

Mike Coffman, Chairman ........................................................................................ 1 

Ann Kuster, Ranking Member ................................................................................ 2 

WITNESSES 

Carolyn Clancy, M.D., Interim Under Secretary for Health, Department of 

Veterans Affairs ................................................................................................... 7 

Prepared Statement ......................................................................................... 33 

Accompanied by: 

Mr. Michael Valentino, Chief Consultant, Pharmacy Benefits Management Service, Veterans Health Administration 

And 

Mr. Harold Kudler, M.D., Chief Consultant, Mental Health Services, 

Veterans Health Administration 

Mr. Randall Williamson, Director, Healthcare Issues, Government Accountability Office ......................................................................................................... 10 

Prepared Statement ......................................................................................... 48 

Ms. Jacqueline Maffucci, Ph.D., Research Director, Iraq and Afghanistan 

Veterans of America ............................................................................................. 11 

Prepared Statement ......................................................................................... 63 

STATEMENT FOR THE RECORD 

The American Legion .............................................................................................. 67 

Deliverable ............................................................................................................... 73 


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PRESCRIPTION MISMANAGEMENT AND THE 

RISK OF VETERAN SUICIDE 

Wednesday, June 10, 2015 

U.S. HOUSE OF REPRESENTATIVES, COMMITTEE ON VETERANS’ AFFAIRS, SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS, Washington, D.C. 

The subcommittee met, pursuant to call at 10:30 a.m., in Room 

334, Cannon House Office Building, Hon. Mike Coffman [chairman 

of the subcommittee] presiding. 

Present: Representatives Coffman, Lamborn, Roe, Benishek, 

Heulskamp, Kuster, O’Rourke, Rice, and Walz. 

Also Present: Representative Miller. 

OPENING STATEMENT OF CHAIRMAN MIKE COFFMAN 

Mr. COFFMAN. Good morning. This hearing will come to order. I 

want to welcome everyone to today’s hearing titled Prescription 

Mismanagement and the Risk of Veteran Suicide. 

Before we begin, I would like to ask unanimous consent that a 

statement from The American Legion be entered into the hearing 

record. Hearing no objection, so ordered. 

This hearing will examine the relationship between veterans prescribed medications as a result of their mental health and the increased suicide rate among veterans. 

In a report issued in November 2014, which included in part evidence uncovered by the O&I Subcommittee, GAO examined VA’s 

data on veterans with major depressive disorder including the extent to which they were prescribed medications, the extent to 

which they received proper care, and whether VA monitored that 

care, and the information VA requires VAMCs to collect on veteran 

suicides. 

It is now clear that VA is not even aware of the population of 

veterans with major depressive disorder due to inappropriate coding by VA physicians. As a result, VA cannot determine if veterans 

are receiving care consistent with the clinical practice guidelines. 

These guidelines are crucial to the treatment of mental disorders 

as they are designed to provide the maximum relief from the debilitating symptoms associated with mental health. It is imperative 

that our veterans receive the proper care and follow-up when receiving mental healthcare, especially when they are being prescribed various medications. 

What has also become clear is that VA is receiving and reporting 

inaccurate and inconsistent data regarding veteran suicides. This 

severely impacts and limits the department’s ability to accurately 


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evaluate its suicide prevention efforts and identify trends in veteran suicides. 

Not only did the committee conduct a hearing in 2010 on this 

same issue, but since then, there have been countless media stories 

of veterans being over-medicated or experiencing adverse drug reactions and not receiving the proper care, the proper follow-up, or 

the proper monitoring, and the all too common result of suicide. 

One story told of a veteran who went into a hospital seeking 

care, but after being, quote, unquote, lost in the system ended up 

dying by suicide right in the facility. We will also hear other similarly tragic stories today that highlight the tremendous problems 

occurring with VA for years and continuing today with regard to 

treatment of veterans with mental health concerns, adequate oversight of treatment programs, and more importantly the actions 

taken to ensure veterans who are prescribed countless medications 

receive proper follow-up. 

Currently VA has approximately ten different programs dealing 

with prescription medication and suicide prevention issues, but it 

does not appear that any of these programs interact with one another. No one is talking to anyone else. How can we ensure that 

the veterans are getting the proper care, the proper follow-up, and 

the proper advice if the right hand doesn’t know what the left hand 

is doing? 

I think it is more appropriate to say based on the statistics from 

the GAO report and the numerous media stories that VA is just 

throwing out a bunch of different ideas and programs hoping one 

of them will stick and they can claim they have solved the problem. 

This is unacceptable. We need to know exactly what VA is doing 

to change this pattern and what is it doing to improve protection 

of veterans. 

What is a real way forward? Who will be held accountable for 

mistakes that have already been made and have cost veterans their 

lives? Who will stand up and take responsibility for making a 

change? It is time for answers. It is time for change. 

With that, I now yield to Ranking Member Kuster for any opening remarks she may have. 

OPENING STATEMENT OF RANKING MEMBER ANN KUSTER 

Ms. KUSTER. Thank you, Mr. Chairman. 

And good morning to our panel. Thank you for being with us. 

This morning, we are addressing a complex healthcare policy 

issue affecting veterans and over 100 million American adults. The 

statistics on veterans experiencing chronic pain are staggering. 

Over 50 percent of all veterans enrolled and receiving care at VA 

medical facilities experience chronic pain, with over a half a million 

veterans managing pain with prescribed opioids. 

As a Nation and certainly in my district and throughout the 

northeast, we face what can only be described as an opioid abuse 

epidemic. The Centers for Disease Control and Prevention has 

termed opioid abuse the worst drug addiction epidemic in the country’s history, killing more people than heroin and crack cocaine. 

In addition to the issue of pain management and the problems 

of addiction, we must remember that many veterans who experience chronic pain also suffer from mental health disorders such as 


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posttraumatic stress and traumatic brain injury. Therefore, it is 

vital that the VA has in place the proper oversight mechanisms to 

monitor the safe use of opioids for managing veterans’ pain. 

I am particularly concerned about veterans at risk of self-medication and addiction being prescribed opioids for pain management. 

We know from multiple inspector general and GAO reports that 

the VA has struggled to properly monitor prescribed opioids and 

the mental health of its patients. And I am concerned that a potential deadly mix of opioid use, mental health disorders, and lack of 

oversight is contributing to our high rate of veteran suicide. 

The newest Drug Enforcement Agency regulations that require 

veterans to see a clinician monthly for a refill of opioid pain medication creates an additional burden on veterans who have difficulty 

accessing care at VA medical facilities, leaving some veterans to 

suffer from extreme pain and experience opioid withdrawal symptoms when they are unable to schedule an appointment to refill. 

This hearing provides us with the opportunity to begin to seriously examine whether the benefits of managing veterans’ pain 

with opioids is outweighed by the risk and side effects experienced 

by veterans and the VA healthcare system’s struggle to properly 

monitor opioid use. 

During this hearing, I would like to hear from our witnesses how 

we can better address safe and effective treatment of veterans 

while ensuring that care management is not forgotten. 

I would like to discuss whether a higher level of informed consent is needed to ensure veterans and their families understand 

the risks and side effects before choosing to manage pain with 

opioids and whether the VA is properly coordinating mental health 

and suicide prevention programs with VA medical facility clinicians 

and employees responsible for monitoring patient opioid use. 

I am also interested in alternative pain management and as I get 

to my comments later, I will talk about what is happening at the 

White River Junction VA in bringing down the rate of opioid prescriptions and how we can help get ourselves out of this problem, 

out of this cycle and address the veterans, to serve their needs 

without putting them and their families at risk. 

And, finally, I would like to discuss what is being done to reduce 

long-term opioid use and treat the underlying conditions causing 

chronic pain so that veterans are able to live a better quality of life. 

Thank you, Mr. Chairman, and I yield back the balance of my 

time. 

Mr. COFFMAN. Thank you, Ranking Member Kuster. 

I will introduce our witnesses in just one moment, but I ask that 

the witnesses stand and raise their right hand. 

[Witnesses sworn.] 

Mr. COFFMAN. Please be seated. 

I would like to recognize the Honorable Jeff Miller, Chairman of 

the full Veterans’ Affairs Committee, who has joined us on the 

dais. 

Welcome, Chairman Miller. You have the floor. 

Mr. MILLER. Thank you very much, Mr. Chairman. 

To the Ranking Member, Ms. Kuster, thank you for the good 

work that this subcommittee has been doing over the last several 

years. 


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If I might, instead of giving a typical opening statement, I want 

to ask Ms. Clancy a couple questions because I need to move on 

to another appointment. 

And I believe, Dr. Clancy, that you have been made aware that 

I am going to be asking a couple of questions, albeit a little bit out 

of order. And I want to talk specifically about Bradley Stone. 

We know that he was seen by his VA psychiatrist a week prior 

to his commission of multiple murders and subsequently dying of 

suicide. He was on many, many prescription drugs and had alerted 

VA, as I understand it, to mental health and physical difficulties 

in the weeks leading up to the incident. 

But it appears that VA said he showed no signs of suicidal or 

homicidal ideations. And I would like to know how did VA come to 

that conclusion that the veteran was okay, and I say that in 

quotes, when he was reporting all of these feelings prior to the incident. 

Dr. CLANCY. In general, people would come to that conclusion by 

asking the veteran a series of questions about were they having 

thoughts of harming themselves and so forth to get some assessment of suicide risk. So my conclusion, if the clinician said, would 

be that the veteran answered, gave negative responses to them. 

Mr. MILLER. Okay. On the 24th of April of this year, I asked the 

department if it would confirm whether or not they had provided 

the full committee with all of the files related to Bradley Stone. To 

date, I have not received a response. So, again, I ask you, has VA 

provided this committee with all of the files on Bradley Stone? 

Dr. CLANCY. I had been told that VA had provided the committee 

with the files with some redactions and had also provided—offered 

an in-camera review. And the redactions were about Social Security 

numbers and some information that was about sensitive details 

about the living family members of Bradley Stone and, again, offered to discuss that with the committee in camera. 

Mr. MILLER. And, again, as I have stated in every single letter 

that I have sent to the department requesting information, an incamera review is not acceptable. That may be what you want to 

provide us, but that is not at all acceptable. And so, you know, the 

staff has informed you and the department that I was going to ask 

particular questions. 

So, again, I ask you, has all of the information—and I would go 

back to I sent the secretary a letter on April 24th where I referred 

to Ms. Diana Rubens, Director of the Regional Office, on April 22nd 

saying that the Philadelphia Regional Office had provided everything related to Mr. Stone’s file. Her response was unequivocally 

yes. 

And so I am taking from your comment today then everything 

that she provided to the central office, the central office has now 

provided to this committee? 

Dr. CLANCY. Since I’m under oath, I’m going to be very careful. 

I don’t—I can’t speak for what Diana Rubens is telling you. I have 

been informed directly by our lawyers that we have provided this 

committee with all the records with the redactions that I mentioned before, again, Social Security numbers and some sensitive 

details about the living family members of Mr. Stone. 


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Mr. MILLER. Okay. I want to for the record, Mr. Chairman and 

Dr. Clancy, I know for a fact that VA has withheld hundreds of 

pages related to the Bradley Stone file. And so with that, I would 

say that we have requested all the documents every way we know 

how. 

So I will ask you one more time, can I expect the department to 

deliver the complete records by the end of this week? 

Dr. CLANCY. I will take that back and I will verify what I’ve been 

told that we have given this committee everything except for 

redactions as I noted earlier. 

Mr. MILLER. Okay. I can assure you it is not redacted. It is missing, completely missing. 

Dr. CLANCY. I will bring that message back. 

Mr. MILLER. We also expect you to deliver the behavioral health 

autopsy unredacted by the end of the week. And I have told VA 

and I will reiterate it again an in-camera review is not acceptable. 

And I ask will you commit that all the documents that I have 

requested will be provided by the end of this week? 

Dr. CLANCY. The behavioral health autopsy is a unique feature 

of what we do at VA healthcare for veterans. Rather than having 

a private limited to the people at the facility, root cause analysis 

or deep dive of what happens when a veteran takes his or her own 

life, this is something that we have centralized so that we can 

learn across the system what kinds of factors might have precipitated the suicide, what could we have done differently or better, 

and it also involves a conversation with the family members of that 

veteran, none of whom have been told that we would be thoughtfully sharing their details with members of the committee. 

And we think that it will have a chilling effect on family members sharing sensitive details and are very, very uncomfortable 

with sharing the behavioral health autopsy. 

Mr. MILLER. Thank you very much for that educational opportunity. 

I refer to you again the fact that we are the legislative branch. 

You are the executive branch. We have complete and constitutional 

oversight over the department and unredacted information or anything that is done within your department that you choose to withhold, we will subpoena it if necessary. 

Can I expect to have this information delivered by Friday? 

Dr. CLANCY. I will take that back, Mr. Chairman. 

Mr. MILLER. Thank you very much. 

And also, I would also like to add on a positive note I was in Cincinnati yesterday. I was in Dayton the day before. I want to thank 

you for the good job that we see being done at the facilities there. 

There has been a great change in Dayton in specifics. And I enjoyed the opportunity to spend a couple of hours with the people 

in Cincinnati. 

We do focus on a lot of the negative and the press likes to focus 

on that as well, but I want to commend you on some of the great 

things and I would hope that some of the good things specifically 

at Cincinnati would be shared throughout VHA and the rest of the 

department. 

Thank you very much. 


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Dr. CLANCY. Well, if I might for one second, Mr. Chairman, first 

thank you very much for that. I know how hard those people work. 

Cincinnati is actually the hub of expertise in intensive care for 

our system, so they actually provide remote assistance to—— 

Mr. MILLER. I had a chance to view it. 

Dr. CLANCY. Did you? 

Mr. MILLER. I sure did. 

Dr. CLANCY. It’s great. It really is. 

Mr. MILLER. Thank you very much. 

Mr. COFFMAN. One point, Dr. Clancy. The VA has turned over 

behavioral health autopsies to this committee before. 

And so, Ranking Member Kuster. 

Ms. KUSTER. Yes. I just wanted to say for the record as a 

healthcare attorney who has worked in this area for quite a long 

period of time in the realm of quality assurance and what the purpose of this type of quality assurance is about when you go back 

and look, it is intended for physicians and the medical team to 

grow and learn from these experiences. 

And I am concerned at the impression that might be left with 

veterans and their families, particularly the family members that 

have been through the trauma of a suicide, that this information 

would be treated confidentially because these hearings, as we 

know, are televised. It is a very public setting. 

And I think we should get to the bottom, but I don’t want to do 

anything that would have a chilling effect on families that are 

sharing the most personal aspects. We already have such a strong 

stigma around mental health and about people seeking treatment. 

And I would be extremely concerned if we left the impression today 

that we are in some way digging into private affairs. 

If there is information about living family members that is not 

relevant, it could be extremely personal. And I guess I just don’t 

understand why we couldn’t do that in a private setting or in a redacted way, why this committee would be trying to determine—and 

I am not speaking as to if you believe there are documents that 

have not been provided. That is a separate matter. 

But I know that under our statutes in the state, confidential information in this quality assurance process is confidential and it is 

not to be shared. And the purpose of that is so that people will 

come forward. So that is my only comment. 

Mr. COFFMAN. Mr. Chairman. 

Mr. MILLER. Thank you very much, and I appreciate the expertise that you bring to this committee and to the subcommittee. 

And you can rest assured, and I think you know that what we 

are trying to do is to hold people accountable. We are not trying 

to release any information that is personally identifiable. This is 

also a murder situation. It is a suicide which is very difficult, but 

a murder suicide. 

And so I believe that while the VA is going through and doing 

this and attempting to find out where things may have broken 

down, the fact is we have gotten this information before from other 

incidents. This one is particularly grievous because of the murders 

that took place. 

And I remind you that we are a federal body, not a state body. 

We are bound by the United States Constitution of which we are 


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given oversight of the executive branch and we are not bound by 

many of the laws, the HIPAA laws and other information to receive 

that information for us to be able to do our oversight in this. And 

it is not political. 

Again, we are trying to get to the bottom of a very tragic event 

and we are trying to partner with the VA as well. And right now 

they are not being as open as they should be. There are documents 

that are clearly missing from the file, documents that I believe are 

damning documents and would put VA in a very negative light. 

I understand that. But you can’t remove those documents from 

the file just because it makes you look bad. And that is what we 

are trying to getting at at this point. 

But, again, I thank every member of this subcommittee for the 

job that you have been doing and look forward to continuing the 

good works. 

But thank you, Ms. Kuster. 

Mr. COFFMAN. Thank you, Mr. Chairman. 

I ask that all other members waive their opening remarks as per 

the committee’s custom. Hearing no objection, so ordered. 

With that, I would now like to introduce our panel. On the panel, 

we have Dr. Carolyn Clancy, Interim Under Secretary for Health 

for the Department of Veterans Affairs; Mr. Michael Valentino, 

Chief Consultant, Pharmacy Benefits Management Service, Veterans Health Administration; Dr. Harold Kudler, Chief Consultant, 

Mental Health Services, Veterans Health Administration; Mr. Randall Williamson, Director of GAO’s Health Care Team; and Dr. Jacqueline Maffucci, Research Director for the Iraq and Afghanistan 

Veterans of America. 

Dr. Clancy, you are now recognized for five minutes. 

STATEMENTS OF CAROLYN CLANCY, INTERIM UNDER SECRETARY FOR HEALTH, U.S. DEPARTMENT OF VETERANS AFFAIRS, ACCOMPANIED BY MICHAEL VALENTINO, CHIEF CONSULTANT, PHARMACY BENEFITS MANAGEMENT SERVICE, 

VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF 

VETERANS AFFAIRS, and HAROLD KUDLER, CHIEF CONSULTANT, MENTAL HEALTH SERVICES, VETERANS HEALTH 

ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS 

STATEMENT OF CAROLYN CLANCY 

Dr. CLANCY. Good morning, Mr. Chairman Coffman, Ranking 

Member Kuster, members of the committee. Thank you for the opportunity to discuss the overuse of medication in the provision of 

mental healthcare to veterans, particularly for those at risk of suicide. 

One of our most important priorities at VA is to keep our veteran 

patients free from harm at all times. I am deeply saddened by the 

tragic outcome involving a veteran. So to families here today or 

watching this hearing who’ve lost a loved one, I want to express 

my sorrow and regret for your loss. I appreciate your sharing your 

experiences with us and will—we will honor your loved ones by 

learning from those experiences and improving care for veterans in 

the future. 


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We acknowledge up front that we have more work to do to reduce opioid use, meeting the increasing demands for mental 

healthcare, and prevent suicides. And we’ve taken significant actions to improve these areas in order to better serve veterans. 

As Ranking Member Kuster said, chronic pain is a national public health problem. It affects about a third of the Nation’s adult 

population and about half of veterans from recent conflicts. 

As a result, a number of veterans and Americans rely on opioids 

for pain control and they can be effective for a while until the side 

effects become quite worrisome. And often mixed with other drugs, 

they can have additional adverse, unintended effects. 

As you noted, Mr. Chairman, we’ve adopted a number of initiatives and tools to advance our goal of safe and effective pain management, making data about rates and doses of opioids as well as 

the other medications a veteran is taking visible at the network facility and most recently at the individual clinician level. 

Starting this July 1, we will be expanding on a very successful 

pilot of an approach called academic detailing which essentially 

consists of one-on-one coaching for every single clinician prescriber 

in our system. 

And in addition to information about effective use of medications, 

it also—this approach also works with clinicians to have the difficult conversations with veterans to help them try other alternatives for pain management and so forth. 

I think it’s important to note that many of the veterans we serve 

come to us as they’re transitioning from military service on opioids 

and other medications and abrupt discontinuation is not possible or 

actually practical. But we have to continue to taper these doses. 

We’ve seen some successes and as you might expect, those with 

the least amount of problems have tended to do better than those 

who are experiencing more severe pain. 

Suicide among veterans is very complex and tragic. Those of us 

who have lost a loved one to suicide know the deep and lasting 

pain. We’ve worked diligently with our scientific partners to understand suicides among those veterans receiving VA care and among 

all veterans across the Nation. 

We know that treatment works. We’ve identified many positive 

outcomes for veterans who are receiving our care. For example, the 

rate of repeat attempts at suicide among veterans who have attempted to take their own lives has declined quite a bit for veterans enrolled in our system. 

Between 1999 and 2010, the suicide rate among middle-aged 

male veterans who use our system fell by 31 percent, at the same 

time that the suicide rate for middle-aged men who are not veterans or who are veterans who don’t use our system actually rose 

during that time period. 

The rate of suicide among women veterans is higher than other 

women in the general public, but women veterans who use our system actually are less likely to die from suicide when compared to 

other women veterans. 

As you know, our research has allowed us to estimate that about 

22 veterans die by suicide every day. What’s less well-known is 

that 17 of those 22 do not receive treatment for care within the VA 

system. And I worry that some of the 17 are actually seen in our 


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system and are fearful about raising mental health concerns because of concerns about the stigma or privacy. 

Suicide prevention efforts have to extend to veterans who may 

not seek assistance. And any veteran who needs help can come to 

any point of entry of care in our system and will be seen that day. 

We’ve also increased targeted outreach efforts to veterans in 

communities throughout the country and we’ve made it easier for 

anyone to call the veterans crisis line. And in response to many 

suggestions from stakeholders, in the very near future, you’ll be 

able to do that when you call one of our facilities directly. You 

won’t have to hang up and call the line. You can just hit a number 

on the phone and that will directly transfer you. 

I really want to express my appreciation to the Congress for the 

Clay Hunt Act and its passage which will expand our capabilities 

to help veterans. So thank you for that. 

The importance of mental health treatments I don’t think can be 

overstated. About 20 years ago in this country, we simply did not 

recognize how important a challenge mental healthcare is for all 

Americans. 

At VA, we have embraced the problems that veterans from returning conflicts brought to us, whether that’s various mental 

health problems, posttraumatic stress, traumatic brain injuries, 

and so forth. And in doing so, we have had to blaze some trails. 

We have had to go ahead of what is going on in the rest of U.S. 

healthcare where utilization of mental health has been pretty dramatically curtailed or utilization controlled over the years. So that 

meant that we have had to work with public and private science 

partners to build the basic science, the epidemiological data, and 

population health expertise. 

We have learned a lot. We’ve made significant gains and seen the 

successes of treating mental health problems, but we have so much 

to do to dispel the stigma linked to mental health issues. 

You know, it wasn’t that long ago that cancer inspired that kind 

of whispering. People didn’t talk about it out loud because of fears 

and misinformation. And, frankly, we hope with your help and the 

help of many partners that soon we’ll be able to eliminate that fear 

and misinformation associated with seeking mental healthcare. 

And in the meantime, we’re focusing on creating an atmosphere of 

trust and privacy. 

I want to just close by saying that we’re committed to improving 

our existing programs, taking every available action to create new 

opportunities, and most importantly improving the quality of life 

for veterans. We’re compassionately committed to serve those who 

have served. We’re proud to have this honor and privilege. 

And we’re prepared to answer your questions and look forward 

to working with you until we get this right. Thank you. 

[THE PREPARED STATEMENT OF CAROLYN CLANCY APPEARS IN THE

APPENDIX] 

Mr. COFFMAN. Thank you, Dr. Clancy. 

Mr. Williamson, you are now recognized for five minutes. 

STATEMENT OF RANDALL WILLIAMSON 

Mr. WILLIAMSON. Good morning, Mr. Chairman and Ranking 

Member Kuster. I am pleased to be here today to discuss our NoVerDate Aug 31 2005 10:21 Jul 26, 2016 Jkt 000000 PO 00000 Frm 00013 Fmt 6633 Sfmt 6633 Y:\98-642.TXT PAT

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vember 2014 report on VHA’s efforts to monitor veterans with 

major depressive disorder referred to as MDD who were prescribed 

one or more antidepressants. 

MDD is a major risk factor for suicide among veterans. It is a 

particularly debilitating mental illness often associated with severe 

depression and reduced quality of life. Also, I will discuss certain 

aspects of VHA’s suicide prevention program. 

Specifically I will discuss the incidences of MDD among veterans 

treated by VA, the extent that VAMC clinicians prescribe 

antidepressants to veterans with MDD and monitor anti-depressant use, and data VAMCs are collecting and reporting on veteran 

suicides to inform VHA’s suicide prevention efforts. 

VHA data show that about ten percent of the veterans receiving 

VA healthcare were diagnosed with MDD and 94 percent of those 

veterans with MDD were prescribed one or more antidepressants. 

However, the estimate of veterans with MDD may be low because 

in reviewing a sample of medical records from selected VAMCs, we 

found that VAMCs did not always correctly report and record confirmed MDD diagnosis among veterans. 

At six VAMCs, we reviewed a sample of veterans with MDD that 

were prescribed one or more antidepressants and found that they 

did not always receive recommended care for three important recommendations in the clinical practice guideline referred to as CPG 

that VA has—VHA has established to guide its clinicians in treating MDD. 

For example, although the CPG recommends that a veteran’s depressive symptoms be assessed using a standardized assessment 

tool at four to six weeks after initiation of antidepressant treatment, we found that for 26 of the 30 veterans in our sample VA 

clinicians did not use this assessment tool at or used it within the 

specified time frame. 

While not mandatory for VAMC clinicians, CPG recommendations are based on evidence-based data from clinical trials, research, and other proven and reliable sources and are meant to enhance outcomes for veterans with MDD. 

Moreover, VHA does not have a process at any level to systematically monitor the extent that VAMC clinicians deviate from CPG 

recommendations. With little, if any, visibility over whether the 

care provided is consistent with the CPG, VA is unable to ensure 

that deviations from recommended care are identified and evaluated and whether appropriate actions are taken to mitigate potential significant risk to veterans. 

Finally, we found that demographic and clinical data in VA’s— 

VA—VAMCs collect on veteran suicides to better inform VHA’s suicide prevention program were often incomplete and inaccurate. 

For example, as part of VA’s behavioral health autopsy program, 

which I’ll refer to as BHAP, VAMCs collect data on veteran suicides such as date of death, number of mental health visits, and 

last VA contact. We examined 63 BHAP reports from five VAMCs 

and found that about two-thirds of them contained inaccurate and 

incomplete information. 

Moreover, this situation is further exacerbated because BHAP reports prepared by VAMCs are generally not reviewed at any level 

within VHA for accuracy, completeness, or consistency. 


VACREP0180 with DISTILLER
11 

Lack of accurate and complete BHAP data limit opportunities to 

learn from past veteran suicides and ultimately diminish efforts to 

develop effective methods and approaches to enhance suicide prevention activities and reduce veteran suicides. 

VA has made good progress in addressing the six—six recommendations to improve weaknesses we noted in our report. In 

the six months since our report was issued, one recommendation 

has been fully implemented and several others are very close to 

being fully implemented. 

More globally, this work illustrates once again a continuing pattern of VHA’s noncompliance with its own policies and established 

procedures, unclear guidance, inaccurate data, and poor oversight. 

These are among the same factors that led GAO to include VHA 

on its high-risk list. 

Until VA instills a culture throughout the organization that 

holds its staff and managers truly accountable for effectively performing their responsibilities, appropriately overseeing outcomes, 

and achieving a recognized standard of excellence, VA—VHA will 

continue to fall short of performing the highest quality and cost-effective care to our Nation’s veterans. 

This concludes my opening remarks. 

[THE PREPARED STATEMENT OF RANDALL WILLIAMSON APPEARS IN

THE APPENDIX] 

Mr. COFFMAN. Thank you, Mr. Williamson, for your remarks. 

Dr. Maffucci, did I say that right? 

Ms. MAFFUCCI. Yes, you did. Thank you. 

Mr. COFFMAN. Thank you. 

And you are now recognized for five minutes. 

STATEMENT OF JACQUELINE MAFFUCCI 

Ms. MAFFUCCI. Chairman Coffman, Ranking Member Kuster, 

and distinguished members of the subcommittee, on behalf of Iraq 

and Afghanistan Veterans of America and our nearly 400,000 members and supporters, thank you for the opportunity to share our 

views and recommendations on prescription management and the 

potential risk of veteran suicide. 

In 2014, IAVA launched its campaign to combat suicide. In February with your help, we celebrated the signing of the Clay Hunt 

SAV Act into law. This was a first step on a long road to address 

the challenges of combating suicide among our servicemembers and 

veterans. 

The issue that we’re here to talk about today is complex because 

it encompasses two topics, providing care for veterans seeking relief from chronic pain, mental injuries, and other conditions, and 

recognizing the potential for misuse and abuse of these powerful 

drugs. And while these drugs are extremely powerful, they can also 

be extremely effective for a veteran who has not found relief elsewhere. 

A 2011 report estimates that chronic pain affects approximately 

100 million American adults and this number is growing. Given the 

last 14 years of conflict and the very physical daily demands on our 

troops, we’ve seen a similar trend among servicemembers and veterans. Over 60 percent the Iraq and Afghanistan veterans seeking 

VA medical care seek care for musculoskeletal ailments and this is 


VACREP0180 with DISTILLER
12 

the most common category for disability compensation. Nearly 60 

percent seek care for mental injury. 

Within IAVA’s own community, two of three respondents to our 

member survey reported experiencing chronic pain as a result of 

their service. One in five reported using prescription opioid medications, one in three using anti-anxiety or antidepressant medications. 

Among this newest generation of veterans, medical advancements have allowed for higher survival rates from complex injuries, 

but this also increases the likelihood for lifelong impacts of nerve 

and skeletal damage. Treatment of pain in these instances can be 

even more complex because co-occurrence with other conditions like 

depression, anxiety, PTSD or TBI may limit treatment options. 

For clinicians, assessing pain and devising a management strategy can be very difficult as well, particularly given that knowledge 

in this field is still growing. Primary care physicians who see the 

bulk of patients with chronic pain report that they feel under-prepared to treat these patients due to lack of training. This includes 

VHA providers who were surveyed in 2013. 

Adding to the challenge are studies showing that untreated pain 

can actually put an individual at higher risk for suicide and, yet, 

we also know that prescription medications can result in strong addictions and provide a means for suicide attempts. 

The VA reports that over half of all nonfatal suicide events 

among veterans results from over—overdose or intentional poisoning. This highlights the challenges that clinicians face when 

treating patients with complex injuries and demonstrates the importance of comprehensive, integrated pain management. 

While the VA has moved the needle forward investing in research on pain, publishing an evidence-based clinical practice 

guideline, implementing an opioid safety initiative, and introducing 

a stepped case pain management system, more remains to be done. 

With approximately 22 veterans dying by suicide every day and 

more attempting suicide, reducing instances of over-medication and 

limiting access to powerful prescription medications must be included in a comprehensive approach to addressing this issue. 

A recent study showed that while patients receiving opioid therapy are at an increased risk for attempting suicide, following some 

of the VA’s clinical practice guidelines reduced this significantly. 

This shows the critical need not only for these guidelines, but full 

implementation of those guidelines. 

VA’s 2009 directive on pain management which outlines the 

stepped care approach to pain expired in October of 2014. While it 

expired in date only and the policy remains active, IAVA is discouraged that updating this important policy has not been prioritized. 

We urge the VA to prioritize this and—and fully implement it at 

all VA facilities. 

IAVA would also like to emphasize the importance of minimizing 

the risk of overdose and over-medication through formulary takeback programs and prescription drug monitoring programs. 

Last year, an important change to DEA regulation expanded authorization for drug drop-off sites. This change gave VA the ability 

to stand up drug take-back programs in their hospitals and this is 


VACREP0180 with DISTILLER
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critical to limiting the possibility of misuse and abuse of powerful— 

powerful prescription drugs, yet no action has been taken. 

And while the VA is working to fully implement its participation 

in state prescription drug monitoring programs, full implementation remains to be seen and we urge the VA to—to prioritize this 

as well. 

Too often we hear the stories of veterans who are prescribed 

what seems like an—an assortment of anti-psychotic drugs and/or 

opioids with very little oversight or follow-up and, yet, we also hear 

stories of veterans with enormous pain and doctors who won’t consider their request for a stronger medication to manage this pain. 

These are tough challenges and IAVA remains committed to working with the VA and Congress to address them. 

Again, thank you for the opportunity to offer our views on this 

important topic. We look forward to continuing to work with each 

of you, your staff, and this committee in this critical year ahead. 

Thank you for your time and attention. 

[THE PREPARED STATEMENT OF JACQUELINE MAFFUCCI APPEARS IN

THE APPENDIX] 

Mr. COFFMAN. Thank you, Doctor. I deeply appreciate your testimony. 

Thanks to the witnesses. 

Dr. Clancy, according to a GAO report, VA deviated from recommended guidelines in most all of the 30 veterans’ cases reviewed 

by not assessing antidepressant treatment properly. 

In your opinion, is policy simply ignored or is there just a lack 

of oversight by leadership? 

Dr. CLANCY. So first I want to say that we regard the GAO recommendations, feedback as very important, a gift, if you will, to 

help us get better. I’m not sure that any guideline written on planet Earth should be followed a hundred percent of the time. Many 

doctors think of them as tools, not rules, because there will be patients with unique circumstances that don’t fit perfectly. 

In terms of the follow-up assessment, I think that is important 

and we need to do a better job. We will be looking to see whether 

that is a feature of the fact that we had—we’re having access problems and it was hard to get people back in or whether we weren’t 

just on the ball. But that is a very important feature. 

Mr. COFFMAN. Dr. Clancy, in our case reviews, we found veterans 

who died of drug toxicity who reported hallucinations and subsequently died by suicide and reported homicidal thoughts. 

Are these the improved outcomes you are referring to? 

Dr. CLANCY. No, they’re not, Mr. Chairman. 

Mr. COFFMAN. Dr. Clancy, in response to the GAO report, VA 

noted that it would conduct chart reviews and develop a plan to determine and address the factors contributing to coding variances. 

This was to be completed by March 2015. 

Has this been completed? 

Dr. CLANCY. It is in progress. We are not completed yet. I will 

also add to that that in addition to that, I have been meeting inspired both by the GAO report and other feedback with Dr. Kudler 

and a couple of the other national mental health leaders in our system to try to figure out who are the veterans who we think are 

struggling the most with mental health disorders that we should 


VACREP0180 with DISTILLER
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be targeting to make sure that they are getting the best possible 

care. 

Mr. COFFMAN. Thank you, Dr. Clancy. 

When do you think that report is going to be done? 

Dr. CLANCY. I would have to double check on when we committed 

to having the recommendations done. 

Mr. COFFMAN. VA has stated it would examine associations between treatment practices and indicators of recovery or adverse 

outcomes for veterans being treated with antidepressants. The target date of completion was also March 2015. 

Has this been completed? 

Dr. CLANCY. I believe that it has. I’d have to double check my 

notes here. Here we are. 

Mr. COFFMAN. Well, can you get a copy of it to the committee? 

Dr. CLANCY. Yes, absolutely. We’ll submit that. 

Mr. COFFMAN. And roughly 63 percent of the behavioral health 

autopsies reviewed by GAO, critical data was missing. 

Is this inaccurate reporting based on incompetence or is it to intentionally keep central office in the dark? 

Dr. CLANCY. I have no reason whatsoever to suspect it’s to keep 

central office in the dark. As I understand it, this program was 

transitioned from doing root cause analyses at individual facilities 

to a centralized repository about two years ago. 

And as you might expect, training reviewers and people who are 

doing the interviews and collecting the data, to collect that data 

consistently and accurately took some time and, frankly, some 

iteration, excuse me, to make sure that we were getting it right. 

Dr. Kudler, do you want to add to that? 

Dr. KUDLER. Yes. At the time the GAO was—oh, pardon me. At 

the time the GAO was conducting this study, the behavioral health 

autopsy program was just being launched. The forms were new. 

They were in need of refinement. They’ve been continuously refined 

as has the training of the suicide prevention coordinators, 300 of 

them across the country at over 150 facilities who fill them out. 

There were questions about, well, what data goes where and how 

do you count this or where do you go with that. That’s now been 

addressed through training and upgrading of our manuals. We’re 

now reviewing all of these centrally at the national level. 

We’ve also created software that crosswalks these to another suicide prevention tracking system, the SPAN system, so that we can 

make sure we’re accurately looking at these from multiple perspectives. 

So the system is continuously improving and it’s progressed a 

great deal since the original report. And we will continue—continue 

to work on it. 

Mr. COFFMAN. Dr. Clancy, this subcommittee has requested the 

behavioral health autopsies for numerous veterans who have died 

by suicide and in all cases except one of Kalisha Holmes, VA has 

stated that this information is confidential, privileged, et cetera, so 

it cannot be released to us. 

If this is true, why was the report for Ms. Holmes released to the 

committee? 

Dr. CLANCY. I would have to take that question for the record. 

I would say in general, the behavioral health autopsy reports—I 


VACREP0180 with DISTILLER
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think the Ranking Member Kuster described this more clearly than 

I could. This is part of quality assurance where you want the most 

forthright kind of input and observations. And if people think that 

this is going to be disclosed, we will not get input that is that forthright. 

Mr. COFFMAN. Well, I think we are very concerned about the fate 

of our veterans and this subcommittee and the committee as a 

whole has an oversight responsibility for your operation. And we 

can’t do that oversight operation and making policy that is best for 

our veterans if you don’t fulfill your obligation and submit that information when requested to the Congress. 

Ranking Member Kuster. 

Ms. KUSTER. Thank you very much, Mr. Chair. 

And thank you to all of our witnesses and particularly Dr. 

Maffucci. 

I really appreciate you being here and sharing with us the recent 

experience of the veterans returning from, as you mentioned, 14 

years of conflict and that the injuries are much more complex. I 

mean, the good news is people are surviving, but the difficulty is 

that, as you say, they have chronic lifelong issues. 

I want to focus in on how we move forward. I share the concerns 

that have been expressed about the data and making sure that we 

are getting at the heart of the issue here. But I am very interested. 

As I mentioned, I had a meeting with the team up at White 

River Junction facility and there is some cutting-edge research, and 

I will talk to the chair about perhaps bringing in some witnesses 

to share that, but particularly the opioid safety initiative. And a 

couple of different things and whichever is the appropriate witness. 

One is getting at the heart of what is causing the pain. My husband has chronic pain and many, many years of back pain and various medications and come to find out what he needed was a hip 

replacement. It wasn’t about his back at all. And now he lives pain 

free with yoga and stretching and exercise and such. 

So I would like to find out what is being done to get at the crux 

of what is causing the pain. Secondly, setting a goal of reducing 

opioid use and working with practitioners to bring down the opioid 

use and particularly emphasizing patient education, close monitoring. 

They talked about actual drug testing because in our area, selling these opioids on the market, what happens sometimes is people 

will not use the medication themself and they can determine that 

through frequent drug testing which, as you can imagine, is not 

popular with the patients but necessary, and then alternative medicine, acupuncture. I mentioned yoga, massage, exercise. 

So if you could comment on this opioid safety initiative. How far 

has that gone? How widely has it been—is it in use and what can 

we do to help move that forward? 

Dr. CLANCY. So thank you. Those are all terrific questions. I’m 

going to start and then turn to Mr. Valentino. 

Like the case with depression, we do have a clinical practice 

guideline that we developed with colleagues from the Department 

of Defense on the management of chronic pain. That was published 

in 2010. It will—as of September of this year, it will be updated 

which is about the frequency you’d want to update these guideVerDate Aug 31 2005 10:21 Jul 26, 2016 Jkt 000000 PO 00000 Frm 00019 Fmt 6633 Sfmt 6633 Y:\98-642.TXT PAT

VACREP0180 with DISTILLER
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lines. And we will be having input from veterans and family members. 

The guideline does include urine drug testing periodically. And 

we have, as I mentioned probably too quickly in my opening statement, made in a series of steps that I would—the umbrella of 

which I would refer to as the opioid safety initiative made data 

about prescribing patterns at the network level, the facility level, 

and most recently at the individual clinician level available and 

visible so that clinicians can actually see what has this patient 

been on over time, what other drugs are they on and so forth. 

Getting to the root of the problem I think is incredibly important. 

I’d be happy to submit for the record to brief anyone any time 

about some of the exciting research we have in process because I 

think it’s very important. 

I think there’s a lot we need to learn in two areas. One is what 

are the predictors of veterans who or anyone who’s likely to use 

opioids for a short time and go down the path of using them on a 

regular basis because if we knew then, that’s where we would target a lot of efforts. 

The second is which veterans are most likely to respond to alternative treatments, to non-narcotic medications and so forth. We— 

as I said, we have some research going on in that area and have 

a lot more to learn. 

Mike, do you want to add to that? 

Mr. VALENTINO. Yes. Thank you. 

So this—the opioid safety program is just shy of two years old. 

And we’ve had to build it from—from the ground up. And as Dr. 

Clancy mentioned, it’s been very iterative. So initially we focused 

on this data collection aggregation to identify outlier—potential 

outlier VISNs. So we focused on those, asked for corrective action 

plans. 

The next iteration was to continue to focus on VISNs, but drill 

down to VA facilities which we did identify outliers, asked for corrective action plans. We know this is working because 17 medical 

centers originally identified have now fallen off the list. 

We are poised right now at this moment and we—we’ve built the 

tools and we’re—we’re validating them for accuracy to drill down 

to the individual provider and patient level. This is very complex 

as you might guess. Someone may show up in data as an outlier, 

but maybe they’re a pain management specialist. Maybe they treat 

cancer pain. Maybe there are other situations where you would expect this. 

So we have to make sure we get it right so there’s confidence in 

the tool, but we’ve had really, really good results. I’ll just name— 

I’ll just go through some of the metrics. 

Since we began, we have 110,000 fewer patients receiving any 

kind of opioid short-term or long-term; 34,000 patients receiving 

opioids and benzodiazepines together which is a known risk; 75,000 

more patients have had a urine drug screen who are long-term 

opioids, as you mentioned, because that is definitely an opportunity 

for—for diversion and we want to make sure patients are taking 

it. 

We have 92,000 fewer patients on long-term opioid therapy 

which we define as longer than 90 days. We also have begun to 


VACREP0180 with DISTILLER
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look at the totality of opioid, the opioid burden. So there are many 

opioid drugs, but you have to sort of boil those down to a common 

denominator, morphine equivalent daily doses. And we now 

have—— 

Ms. KUSTER. Mr. Valentino, I am sorry. My time is up. I am very 

interested—— 

Mr. VALENTINO. Okay. 

Ms. KUSTER [continuing]. In what you have to say, but my colleagues need their turn as well. So thank you so much and we can 

take that on the record. 

Mr. COFFMAN. Mr. Lamborn, Colorado. 

And let’s see if we can not try and run the clock out on some of 

these answers. 

Mr. LAMBORN. Well, I would like to thank the chairman for 

bringing this important issue to light. 

Unfortunately, it comes too late for one of my Colorado Springs 

families. I would like to tell you the story of Noah, a former marine 

who served with honor in Iraq in 2009 and Afghanistan in 2011. 

I won’t use his last name, but his parents have offered the use of 

his picture, so if I could just show you Noah’s picture. 

After leaving the marine corps, Noah began work on a business 

degree at the University of Colorado at Colorado Springs and started his own online business based out of Colorado Springs. 

Noah comes from a military family, his dad having honorably 

served for 23 years. Noah chose to put off college so he could serve 

this great Nation. Unfortunately, his parents are appalled by the 

care that their son didn’t receive from the VA. They believe their 

son would still be alive had he received better care. 

Noah was diagnosed with PTSD and received a 50 percent disability due to PTSD. On April 2nd of this year, he went to the Colorado Springs VA clinic where medical notes from his visit state 

that he had suicidal thoughts or suicidal ideation specifically. Noah 

was prescribed a psychotropic drug, Venlafaxine, and sent on his 

way. 

Now, we don’t know at this time what this drug did or didn’t do, 

but we know this. He was not referred for suicide prevention. He 

was not offered counseling and there was no follow-up from the VA. 

He went missing the evening of May 4th and was found dead from 

an apparent suicide May 12th of this year, a month ago. 

As you can imagine, his family is devastated. They are asking a 

lot of serious questions, so, Dr. Clancy, I would like to ask you several questions on their behalf. 

Why was their son who had been documented with having suicidal thoughts or ideation not referred to suicide prevention? Why 

wasn’t there follow-up from the VA and why wasn’t he offered 

counseling? 

Dr. CLANCY. I will look into this personally, Mr. Congressman. 

That’s heartbreaking. I can’t even imagine what this—I can imagine, but I know it’s horrendous what his family is going through. 

The picture was worth many, many words as someone who did so 

much for this country. And I will look into that and get back to you 

on these and to the family. 

Mr. LAMBORN. Would one of the other witnesses have any response to my questions, to the family’s questions? 


VACREP0180 with DISTILLER
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Dr. KUDLER. You know, as a psychiatrist, as somebody who’s 

treated veterans in clinics for 30 years, it’s hard to understand the 

report that we’re given and, yet, these seem to be the facts that are 

available. We have to look into it. 

My first thought is that I want to make sure this family has been 

reached out to directly and that we have a chance to collect this 

information. As I say, we’ve created a system. A system can be cold 

and inhuman, but we need to have a real sit down with them and 

understand everything that happened from their point of view, 

questions that they have which may torture them, and we will 

work with them to do that. 

Mr. LAMBORN. Okay. Thank you both. 

Mr. Chairman, thank you for having this hearing and I yield 

back the balance of my time. 

Mr. COFFMAN. Mr. O’Rourke, Texas. 

Mr. O’ROURKE. Thank you. 

Dr. Clancy, a question to which I would like to receive a quick, 

direct answer. We are touting reduced prescriptions of opioids as 

though perhaps that in itself is success. 

What I would like to know are the consequences. I have veterans 

that show up to my town hall meetings saying that their prescriptions were cut off without notice, without transition, without 

ramping down. 

How many of those who are no longer receiving prescriptions 

from the VA are now using heroin or other street drugs? 

Dr. CLANCY. We can’t know that without—with the information 

that we have. It is something we worry about constantly. So—— 

Mr. O’ROURKE. Let me tell you another problem. This is just 

hopefully helpful feedback for you from El Paso. Others who have 

prescriptions are required to renew those prescriptions after a 

monthly visit with their prescriber. They are unable to get the appointment in El Paso to see the prescriber, so they cannot get the 

prescription renewed. So they go without or they go with something 

that they shouldn’t have that perhaps they buy on the street. And 

at a minimum, they are suffering. And in some cases, I would connect that suffering to suicides that we see in El Paso. 

I would also like to give you the following feedback. As I shared 

with you when I met with you on Monday, the May 15th access report from the VA shows that El Paso is ranked 157 out of 158 for 

mental healthcare access. We have 115 mental healthcare positions 

approved for El Paso. Only 87 of those are filled, leaving a 24 percent vacancy rate. 

Your predecessor, when we would relay anecdotal information 

that I was hearing from veterans, told me we were seeing everybody within 14 days. As you know, we did our own survey and El 

Paso found that more than one-third of veterans could not get a 

mental healthcare appointment, not in 14 days, not in a month, 

just not ever. 

That situation, because we are surveying the veterans again 

right now and we are receiving the responses back, has not improved in the year that we have had new leadership there. This 

should be for you a five-alarm fire. 


VACREP0180 with DISTILLER
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I have met with the widows and the mothers of suicides in El 

Paso far too often and I am continuing to do that. And I just did 

the last time that I was home in El Paso. 

As you know, for whatever reason, the VA has been unable to 

solve this issue and to treat it as a priority that it should be and 

to turn around El Paso. I am glad to hear that there are good 

things happening in other parts of the country, but everything that 

I do and view is through the prism of the veterans that I serve in 

El Paso. 

You know that we have a proposal from the community in El 

Paso to address this. I want your commitment that you are going 

to work with us because the community has come forward in the 

vacuum of VA leadership and action and will and resources to do 

the right thing. 

I will do whatever it takes to work with you and your team and 

the secretary to get this implemented, but this is a crisis that has 

deadly repercussions for the veterans that we all serve in El Paso. 

And I want to make sure because we didn’t take it seriously over 

the last year because our statistics and our vacancy and our position relative to mental health access is actually worse than it was 

a year go, I want your commitment that you are going to work with 

me to resolve this, that it is a crisis for you, that it is urgent for 

you, and that we are going to turn this around. 

Dr. CLANCY. You have my full unwavering commitment. We were 

very impressed with your reaching out and bringing in various 

members of the El Paso community to work with us. And I want 

to thank you for your support of our employees during what was 

a different kind of tragedy at the El Paso facility several months 

ago, something that cut to the heart of clinicians across the country, but particularly to those serving veterans in El Paso. You have 

my full commitment. 

Mr. O’ROURKE. Thank you. 

I yield back. 

[Disturbance in hearing room.] 

Mr. COFFMAN. All right, sir. I am sorry. You are out of order. You 

are out of order. Thank you. 

Dr. Benishek, Michigan. 

Dr. BENISHEK. Thank you, Mr. Chairman. 

Well, I want to associate myself with the comments of Mr. 

O’Rourke for one thing and that is I have seen this as well is that 

the goal seems to be cutting down the amount of narcotics. And the 

same circumstances happen in my district, too, where people have 

just had their prescriptions cut off with no alternative treatment. 

Figure it out. It has been a real problem. 

There are a couple of specifics I want to get to after that and 

that is something Dr. Kudler said and then something Mr. 

Williamson said. And Mr. Williamson said there is not that much— 

there doesn’t seem to be that much follow-up on this, the behavioral health autopsy program or we are learning moving forward. 

Can you remind me what you said in your testimony, Mr. 

Williamson, because it seemed like—— 

Mr. WILLIAMSON. We were talking about—— 

Dr. BENISHEK [continuing]. You were contradicting what Dr. 

Kudler said. 


VACREP0180 with DISTILLER
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Mr. WILLIAMSON. I was talking about oversight. VA conducts 

very little over the suicide prevention of that program at the local 

or the national level to see whether data were accurate and complete. 

Dr. BENISHEK. Right, right. Now, Dr. Kudler, you said that you 

are doing oversight and Mr. Williamson said the GAO says you are 

not. So what is exactly going on? 

Dr. KUDLER. The difference is the two years that have passed 

since this report was written. I’m not questioning the report at all. 

In fact, I find the report helpful as a real spur to do more. 

Dr. BENISHEK. All right. 

Dr. KUDLER. At this point, we are making a difference in this. 

We’ve developed programs to address—— 

Dr. BENISHEK. Could you show me the results of the oversight 

that you have done in the last two years? Could you get that to me, 

you know, within a reasonable period of time, like a month? 

Mr. WILLIAMSON. That’s—that’s not quite the way it is, I think. 

I think there is still—to respond to our recommendations on oversight, I don’t think VA has completed those yet. It’s not the two or 

three-year lag at all. I think what we’re talking about there have 

been some changes made. There’s now a box checked on the—on 

the behavioral autopsy report that indicates that oversight has 

been done, but we know that hasn’t—— 

Dr. BENISHEK. That is all there is is a box you are saying, right? 

Mr. WILLIAMSON. Well, that’s one of the things. And—and they— 

they are revising guidelines and so on. They are making progress. 

I’m not going to—but it’s not been completed to our understanding. 

Dr. BENISHEK. I am not going to give you another chance, Dr. 

Kudler. Sorry. 

But, Dr. Clancy, you said something in your testimony that was 

very important to me and that is this seems so simple, but the fact 

is that people who have an idea that they want to hurt themselves 

have to hang up and dial another 800 number when they are calling into the VA. And you spontaneously said that you are going to 

have that fixed and be able to just, you know, hit a key and make 

that work. 

So what I want to know is when. Can you give me a date when 

that all happens that I can call the number and see if it is actually 

working? 

Dr. CLANCY. Absolute—— 

Dr. BENISHEK. When is that going to happen? 

Dr. CLANCY. Absolutely by November or December. One of the 

things that we have been working very closely with the veterans’ 

crisis line—— 

Dr. BENISHEK. Great. No. 

Dr. CLANCY. We just want to make sure—— 

Dr. BENISHEK. I don’t want you to go on about what happened. 

Dr. CLANCY [continuing]. That we don’t overstress that system 

when we do it. 

Dr. BENISHEK. I just want to have a date so that if it is not there 

by November or December—— 

Dr. CLANCY. Yes. 

Dr. BENISHEK [continuing]. Because I completely agree with the 

guy that stood up here in the back and was out of order in that, 


VACREP0180 with DISTILLER
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you know, it is just great to keep hearing that you are going to all 

do work, but from where I sit, you know, the actual accomplishment of the job does not seem to be happening. 

So I just—— 

Dr. CLANCY. No, I hear that. 

Dr. BENISHEK [continuing]. I will be back to talk to you in January and hopefully that I have called those places and there actually 

is a number I can hit because, I mean, I got people calling me all 

the time. 

Dr. CLANCY. I’ll be checking before you will. 

Dr. BENISHEK. This is ridiculous. 

Dr. CLANCY. But, yes. 

Dr. BENISHEK. All right. With that, I think I will yield back the 

remainder of my time. Thank you, Mr. Chairman. 

Mr. COFFMAN. Thank you, Dr. Benishek. 

Mr. Walz of Minnesota. 

Mr. WALZ. Thank you to the chairman. 

And thank you all for being here today. 

And I, too, would like to hit on this, the OSI that was implemented in Minneapolis. And we followed this closely since October 

2013 and we are getting the results. But I think my colleagues, I 

would associate with them. 

And I know this is nothing new to all of you that we saw a dramatic increase in calls to our office after it was implemented which 

I think probably is somewhat expected, but I think the lack of 

maybe being there or the alternative. And I say this very clearly. 

This issue of mental health parity, mental health treatment certainly is societal-wide. 

I am very proud of the work that this committee has started, a 

small first step on Clay Hunt, but it is going to be the broader 

issue. 

And on the opiate issue, this Nation has vacillated back and 

forth from over-prescribing to under-prescribing and trying to find 

this as the research gets it. So I hear that. 

I guess my concern and the frustration, and you hear authentic 

frustration from veterans, whether it be here or all the time, this 

pain management thing is a tough one, tough, tough, tough. It is 

tough and I always say this, but I think it is important for context. 

I represent the Mayo Clinic area, so these are folks dealing with 

this also on a very big issue. 

But I was very proud back in 2008. One of the first bills I was 

able to move through was the Military Pain Care Act and Veterans 

Pain Care Act. And out of that came the VHA’s pain directive 

2009–053. And what it was is we put together through IOM the 

stepped care pain model which is the old standard, the best practice; is that correct? 

Dr. CLANCY. Yes. 

Mr. WALZ. Okay. And I won’t go through all of it that is here, 

but what I would say is is that it had a five-year span on it. I 

wanted to go further, but this is the nature of how we do legislation. It expired in 2014 before it was fully implemented. It did not 

get reauthorized. 

But when we were out in Toma on this issue, Dr. Clancy, you 

responded, and this was on March 30th, that the VA doesn’t need 


VACREP0180 with DISTILLER
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us to do it, that you can put it in yourself. And I said that is wonderful. Let’s do it. And I followed up with a written letter and I 

don’t expect to be a high-maintenance person, but I have heard 

nothing on my specific question. 

So the frustration lies in this was seven years ago, we were dealing with pain management. Seven years ago, we implemented best 

practices. Seven years ago, the VA started but didn’t fully implement it. Eight months ago, it expired. Three months ago, I asked 

about it. 

And I hate the exchanges that we continue to have. I hate the 

pattern of communication that we now have because it does not 

bode well for our veterans. It does not fit. In fact, it is very irritating. 

So I don’t set you up to get up because I wanted to start and 

preface this that I understand the challenge of this issue. I understand the deep societal issues. I understand the positives we are 

making and the pluses and minuses. The frustration lies more in 

that this might not have been the fix, but why didn’t we do it? Why 

aren’t we? 

Dr. CLANCY. It has been done. It is still being reviewed internally. And I will be honest and say this is an issue that the GAO 

highlighted in putting us on their high-risk list. And we have got 

to get better at the process and updating of our policies and directives. But the pain directive has been updated. All policies—— 

Mr. WALZ. Who knows that? 

Dr. CLANCY. Yes? 

Mr. WALZ. Who knows that? Would the author of the bill not be 

someone who would need to know that? 

Dr. CLANCY. Well, we’re going to tell you as soon as we have reviewed it and made sure that we have gotten consensus and we 

haven’t missed any details. And I apologize. I have not personally 

seen your letter, but I will make sure that I do see it before the 

day is over. 

Mr. WALZ. Part of this is, and I go back to that, and, again, I 

don’t expect to be high man, you got other priorities to get on here, 

but this is one of the issues we have struggled with is this very 

thing. Our job is tasked to do this. 

We think we had a pretty good—not us. We built a great coalition from private companies like Boston Scientific to working with 

your talented people in this. We got a good piece of legislation on 

it. We are trying to communicate to implement it and we are left 

in a no man’s land where we don’t know what to think. 

I don’t like going out and hammering on you that we haven’t 

heard from it yet, but this is important stuff. And there are some 

things and I encourage my colleagues to look at this. The things 

I hear the ranking member asking to put in, she is intuitively 

clicking into this. That is in the stepped care pain management. 

The things that you are hearing from Dr. Benishek are in the 

stepped care. And if we just get it out there, get it implemented, 

make it best practices, make it SOP, it would be there. 

So, again, I encourage you in many cases if you are doing something right, let us know and talk about it, communicate with us, 

see us as partners in helping our veterans, so the frustration you 


VACREP0180 with DISTILLER
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hear both here and out in our districts is reduced. So we will look 

forward to the follow-up. 

And I yield back. 

Mr. COFFMAN. Thank you, Mr. Walz. 

Dr. Roe, Tennessee. 

Dr. ROE. Thank you, Mr. Chairman. 

And just a couple of things. One on data collection. And certainly 

when you draw or produce inadequate data, you draw inadequate 

results. And the results may not be accurate at all. And it is extremely important in healthcare to get the data right because we 

are going to draw conclusions based on this many patients did this 

and this many patients did that while the outcome—I mean, I have 

been involved in those clinical studies for years. 

And when you put BS in, you get BS out. And so that is sort of 

what it looks like has happened right here. And that is being a little crude, but that is absolutely what it looks like you have done. 

And Mr. Williamson has pointed out, I mean, you have got half 

of the BHAP templates were incomplete or inaccurate. You draw 

bad conclusions from that. You can’t help but do it. So I think until 

you get the data right, you are never going to know. You are going 

to have one—and, Dr. Clancy, you are right. What works for one 

patient may not work for another. 

And the ranking member certainly has pointed out there are 

many alternative therapies and what works. And Dr. Murphy 

whom I am sure you know continually complains about when he 

is at DoD and has a patient stable and then they are separated 

from the military and they go to the VA, there is a different formulary there, so they then stop all of what he has taken forever 

to get the patient stable on and they are now on something else. 

So I think that is something that needs to be addressed. He was 

very adamant about that he sees it a lot since he is still in clinical 

practice. 

And I, too, with Dr. Benishek want to associate myself. I think 

the outburst that you heard was just frustration from probably a 

veteran who has either tried to get in or couldn’t. And Mr. 

O’Rourke has every right to be frustrated when he has people lined 

up outside his office talking about not being able to get in the VA. 

And let me share why that is frustrating to me. I have been here 

six years and change on this committee and we have increased the 

budget 74 percent. It is not money. It is management. And it is not 

the amount of money that we are spending on our veterans. There 

is plenty of money out there to spend. And I don’t understand why 

the system isn’t functioning better. 

Any comments on that because, Mr. Williamson, I think you 

pointed out in your testimony poor oversight? Why is that? No accountability. What happens to someone when we find out they are 

just not following it? Apparently nothing. So I know there are outcomes. You mentioned all of those things. 

Mr. Williamson. 

Mr. WILLIAMSON. So your question is directed at oversight? 

Dr. ROE. Yes, sir. 

Mr. WILLIAMSON. Yes. There’s a lot of reasons why oversight 

doesn’t happen. And VA does not have the data perform to rigorous 

oversight. 


VACREP0180 with DISTILLER
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I don’t think there’s any willful motive on VA’s part. I think it’s 

just that oversight is missing especially at the local level. At that 

level, accountability is missing; supervisors are not holding employees accountable for doing their jobs correctly. 

Dr. ROE. But that seems basic to doing your job to me. I mean, 

to hold someone accountable for their job, I mean, that is not rocket 

science. You are not doing your job, so what happens when you 

don’t do your job? Do you lose your job or what happens? 

Mr. WILLIAMSON. I’m not sure I’m the right one to answer that, 

but in an idealistic world, I would think you would lose your job 

if you are not performing. We should be held accountable for the 

quality of the work that we do. When we don’t do it well, we get 

feedback. First of all, we should be given expectations, then we get 

feedback and hopefully corrective action after that. And that’s basically business 101—it’s common. 

Dr. CLANCY. So, Dr. Roe, if I might, I want to say that to you 

and your colleagues we share your frustration. And I want to salute my colleague, Dr. Kudler, who is working with others to try, 

yes, so when people who don’t do their job should be held accountable if, in fact, we have given them the resources and the capacity 

to do that job. You can’t hold somebody accountable if there are no 

appointments and no ability to see a patient in follow-up. 

Dr. ROE. But Mr. O’Rourke pointed out that there are 20 something people, jobs available right now. We claim we have a job 

problem. 

Dr. CLANCY. Yes. 

Dr. ROE. There are 24 people that need a job in El Paso, Texas 

and there is money there to fund it. So why aren’t those positions 

filled? 

Dr. CLANCY. We have tried a lot of varieties of ways to recruit 

people. Mr. O’Rourke came in with a group of partners from the 

community. And I think I’m very much looking forward and he has 

my full commitment to looking at that proposal to see how we can 

be working—— 

Dr. ROE. And VA is not making—— 

Dr. CLANCY [continuing]. With them more effectively. 

Dr. ROE [continuing]. It hard for those veterans to leave that system and go to these private practitioners. It is with the veteran’s 

choice card or with a non-VA care because we find that sometimes. 

It is just so hard with all the rules they have to get, it takes forever for someone to get an appointment. 

And one last thing. I know my time is expired. But how long does 

it take to change a phone number to get—why does it take six 

months to have some—when you call—and I know how frustrated 

I get when I call. Punch two for this and three for that. It makes 

me want to throw my phone away. 

How hard is it to do when someone is contemplating suicide to 

have a phone change to where they go straight to a person, a 

human being—— 

Dr. CLANCY. We wanted to make—— 

Dr. ROE [continuing]. On the other end? 

Dr. CLANCY. We want to make sure that we don’t overstress the 

people who are taking the calls, one of whom recently took their 

own life. As you can imagine, that is a very, very stressful job. So 


VACREP0180 with DISTILLER
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that’s the reason we’re just testing it first in about 20 different facilities this summer. And we’ll then roll it out full steam this fall. 

Dr. ROE. That may be stressful and I am very sorry for that family, but it is very stressful on the other end. That is why they are 

making the call. 

Dr. CLANCY. No, I understand that completely. And we—we want 

to make sure that when you do hit that one number or whatever 

the number will be that, in fact, it connects you directly to a counselor because the only thing worse than not having it is doing it 

then. 

And I do have to say that the issue of transitioning 

servicemembers over to VA, they continue on the drugs that they 

were getting in the service. We’ve gone over this with Dr. Woodson 

at the Defense—— 

Dr. ROE. I will ask Dr. Murphy today again when I see him on 

the House floor. He is under a different impression. So I will have 

him check. 

Dr. CLANCY. Well, and I would be happy to follow-up with him 

as well because if we’ve missed something in our surveys of veterans, we want to know about that and fix it. 

Mr. COFFMAN. Ms. Rice, New York. 

Ms. RICE. Thank you, Mr. Chairman. 

I mean, I hate to say that maybe the stress for the poor operators comes from the fact that they know that they are not going 

to have the support from the VA in getting the callers the help that 

they need. 

I would like to take a minute to recognize the work that is being 

done in my home state in a VISN that covers the Bronx and Manhattan. They specifically reject the prescribe first, diagnose later 

treatment philosophy that I think is all too often adopted by the 

VA. They have taken again what shouldn’t be a revolutionary approach to pain management, but it is. They actually believe that 

the first thing you do is diagnose the patient before developing a 

path of treatment. And instead of prescribing opiates as the default 

treatment for veterans suffering from pain—and I understand that 

doctors when a patient comes and presents with real pain, you 

want to take away the pain. I get that that is the doctor’s mode 

of reaction. 

But this facility is using alternative approaches such as acupuncture and exercises to relieve pain. And what we have seen is veterans who undergo these treatments experience a relief from pain 

without the harmful effects of addictive narcotics. The Bronx VA’s 

outstanding approach to pain treatment should become the norm at 

all VA facilities nationwide. 

My question is to you, Dr. Clancy. What is the VA’s version to 

alternative forms of treatment like meditation, acupuncture, and 

exercise? 

Dr. CLANCY. First of all, let me say I completely share your enthusiasm for what I believe it’s VISN 3 is doing. 

Ms. RICE. Yes. 

Dr. CLANCY. And I have spoken to those folks. It’s wonderful. 

And we have many thousands of veterans actually using alternative forms of therapy. So there is no aversion whatsoever. 


VACREP0180 with DISTILLER
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For veterans who are already getting opiates like other Americans and some of whom come to us from active duty on those same 

medications, the path forward is going to be different. It’s not starting from day one. So I love what they’re doing in New York. 

And I have spoken with many veterans and have actually begun 

to think about how we might use their stories to help those who 

are struggling to get off opioids and try alternatives. Many of the 

veterans who take opioids would like not to, but they’d like to kind 

of wake up and it would all be okay. The journey there is not so 

easy. 

So we actually have to—— 

Ms. RICE. Because we have a system here that you know works. 

And I think it was one of my colleagues who told the story about 

Noah and clearly he was just prescribed drugs. He was not given 

any follow-up, any alternative, any, you know, therapy, anything 

like that. 

The doctor who is in charge of VISN 3, Dr. Klingbeil, she made 

a statement that I thought was very accurate. She said that to be 

on opiates is to be trapped in a cycle of poor function and poor pain 

control. And that is what we need to get away from. 

And I am just imploring you. It is not rocket science. They get 

it right there. Just export it throughout the rest of the country. 

One other thing that I wanted to talk about is a bill that I happen to be a proud cosponsor of that is put forth by our colleague, 

Ron Kind from Wisconsin. It is H.R. 1628, the Veterans Pain Management Improvement Act, which would establish a pain management board within each VISN to better handle treatment plans for 

patients with complex clinical pain. They would incorporate doctors, patients, family members into the decision-making process for 

a veteran’s course of treatment. 

Has the VHA taken the ideas in this bill under advisement? 

Dr. CLANCY. Yes. Representative Kind asked us for our comments and I told him he had my personal full thread of support 

which may be different than the department’s support. But I can’t 

think of anyone who would—I can’t think of any reason we would 

not support that fully. 

It was really inspired by that that in updating our clinical practice guideline I wanted to make sure that we had input from veterans and families in doing just that. And I told him that. I think 

that’s—because as heartbreaking as some of the experiences of the 

veterans are are the experiences of families who raise their hands 

and said I’m worried about my son, daughter, spouse, whatever, 

and didn’t feel—— 

Ms. RICE. It is a family issue. It is not even just a serviceperson 

issue. It is—— 

Dr. CLANCY. Yes. 

Ms. RICE [continuing]. An entire family issue. And I don’t think 

that we want to be a Nation that says to our brave men and 

women who fight for us—— 

Dr. CLANCY. I agree. 

Ms. RICE [continuing]. And come back so damaged and so injured 

that we are going to do our best to keep you in a catatonic state 

for the rest of your life as a pain management therapy. That just 

cannot be where we come down on this. 


VACREP0180 with DISTILLER
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So I am begging you to do everything that you can to look at 

what they are doing in VISN 3 and export it throughout the rest 

of the country. It is not rocket science. 

Thank you very much, Mr. Chairman. 

Mr. COFFMAN. Thank you. 

I think if I was going to sum up this hearing with the Veterans 

Health Administration, it would simply be that drugs are a shortcut. They are a shortcut to doing the right thing. They are a shortcut to doing the therapies that are really required to treat our veterans both mentally and physically in terms of management and 

in terms of those suffering from depressive disorders. And I think 

that that is disconcerting and it is unfair and hurtful to the men 

and women who have made tremendous sacrifices for this country 

in uniform. 

And one question that I have is, how many physiologists or rehabilitation physicians does the Veterans Administration have, Dr. 

Clancy? 

Dr. CLANCY. I would have to take that for the record, Mr. Chairman. 

Mr. COFFMAN. Well, I’ve got the number of about 40. 

Dr. CLANCY. And I’ll get back to you. 

Mr. COFFMAN. I’ve got the number of about 40. So, I mean, therein lies part of the problem. Those are the people central when it 

comes to pain management and, yet, we are shortchanging that because, again, the easy thing to do is to drug somebody, drug them 

not to feel pain, drug them to get them up in the morning, drug 

them so they can go to sleep at night. 

And I think when we look at the suicide rates of our veterans, 

that is reflective of what the Veterans Administration is doing in 

terms of having drug reliant therapies again as a shortcut for doing 

the right thing. 

Dr. Maffucci—— 

Dr. Maffucci. 

Mr. COFFMAN. Maffucci. Okay. I got it right now? 

Dr. MAFFUCCI. Yes. 

Mr. COFFMAN. And are you a veteran yourself? 

Dr. MAFFUCCI. I am not. I’m a neuroscientist by training and 

prior to IAVA worked for the Pentagon on behavioral health issues 

with the Army Suicide Prevention Task Force and other—other 

programs. 

Mr. COFFMAN. Well, I want to thank you for your work on behalf 

of the men and women who served this country. 

What is your view about—I mean, do you believe that, in fact, 

the over-prescription of drugs is a shortcut? 

Dr. MAFFUCCI. I think this is a really complex question to ask 

because if you look at the history of—of clinician education, medications have always kind of been at the forefront, particularly with 

pain management. 

As a neuroscientist, I can tell you the research is still very young 

in understanding how pain manifests, how it manifests in individuals. Every individual experiences it differently. And because of 

that, we also don’t have a lot of great treatment options. 

However, having said that, there is a lot of research coming out 

right now that really supports this idea of integrated management 


VACREP0180 with DISTILLER
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of pain using alternative and complementary medicines. There is— 

there are some—spinal cord stimulation is a new technology that’s 

out there. 

And IAVA actually has a member veteran who was addicted to 

opioids, was a chronic pain sufferer and was able to get off of those 

drugs and through spinal cord stimulation and through alternative 

practices lives a much better life now as a result. 

But these are all very new technologies. Doctors don’t know 

about them. They’re not using them. And so clinician education is 

so, so critical to redefining how clinicians look at pain management. 

Mr. COFFMAN. Well, I think you would agree, though, that drugs 

should not be the first course of action? They should be the last 

course of action? 

Dr. MAFFUCCI. Absolutely. I think drugs are—drugs are one option of many and they might be necessary, but they shouldn’t be 

the—the end all be all. They need to be a part of a comprehensive 

plan. 

Mr. COFFMAN. Mr. Williamson, how would you view in terms of 

the principal modalities or treatment, whether for psychotherapy or 

for pain management? From what we are seeing here in terms of 

testimony, it seems to be kind of the first and preferred method of 

treatment tends to be drug therapy. 

Mr. WILLIAMSON. Well, I’m not a clinician and I’m really not 

qualified to answer that. But GAO will be looking of the opioid program, later this year. So I’ll be much more educated after we finish 

with that study. 

Mr. COFFMAN. Well, that is not comforting. We were prepared 

here to know. 

Dr. Kudler, what do you think? 

Dr. KUDLER. I’m really glad you asked that question. 

Mr. COFFMAN. Yes 

Dr. KUDLER. No. 

Mr. COFFMAN. Let’s—— 

Dr. KUDLER. No, no. The bottom line—— 

Mr. COFFMAN [continuing]. Not run the clock here. 

Dr. KUDLER. The bottom line is this. Whether it’s pain or depression, it takes an integrated approach just as Dr. Maffucci was saying. And different patients need to start in different places. There 

are patients who will say I can’t talk about this. I won’t talk about 

this. And the medication will make that possible in the depression 

case. 

In a pain case, there are people who absolutely need not to go 

where they mean to go into opiates or come off them, but they believe this is all that would ever work for me. So we need to start 

where the—where the patient is, where the veteran is and use a 

mixture. 

With my patients, I’ve always said, look, I have a lot of different 

tools, talk therapies and medication. This is the good and the bad 

about each of them. What makes sense to you and, by the way, we 

can do both. And in most cases, we end up doing both, but often 

the stepped way. 

Mr. COFFMAN. Dr. Clancy, in an OIG report from 2013, it was 

recommended that VA ensure that facilities take action to improve 


VACREP0180 with DISTILLER
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post-discharge follow-up for mental health patients, particularly 

those who are identified as high risk for suicide. 

What is being done to ensure that this process is being followed? 

Dr. KUDLER. A few years ago, VA put out as a performance 

measure that veterans must be seen in person or at least by phone 

in the first seven days after leaving a psychiatric hospital. And this 

is based on statistics that show this is the most vulnerable time. 

Actually, the first two weeks, the most vulnerable time for a suicide attempt, especially after treatment of depression or admission 

for suicide activity. 

We’ve been monitoring this. We are not perfect in this, but we 

have—we—we are—I—I can’t give you the number now. I can provide it later. We are now at a point where all across the Nation, 

we’re tracking this. We have automatic alerts. We have teams that 

do this work with people. And we’ve taken it miles further. I wish 

I could give you the exact number right now. I can provide it. 

Mr. COFFMAN. You know what is amazing is from what we are 

hearing on the ground and from what we are hearing in this committee, it is a world apart. And if for what we are hearing in this 

committee were true, we wouldn’t be here today having this discussion. 

Ranking Member Kuster. 

Dr. CLANCY. Well, Mr. Chairman, if I might, we’re not saying everything is fine and I acknowledged that at the outset. What I did 

want to tell you is that we are committed to getting it right. This 

is tough work and we have a lot to improve on. And we very much 

welcome your support and help. 

Mr. COFFMAN. Very hard to get it right if you are not acknowledging the depth of the problem. 

Ranking Member Kuster. 

Ms. KUSTER. Thank you very much. Thank you, Mr. Chair. 

And thank you to our committee, to our panel for coming forward 

and all the comments from the committee. 

I just want to follow-up on where we go from here in terms of 

sharing best practices. We have now heard Dr. Maffucci. I really 

appreciate again your commentary and your expertise in this area 

and to the team from the VA. We have heard about VISN 1. I 

talked about some examples in White River Junction. 

How do these best practices get shared and the research that is 

underway, how do we move forward with this to make sure that 

more veterans and their families will be served by this and in particular the clinician education because I think we have got to 

change some of the parameters and some of the, you know, sort of 

go-to answers that some of the clinicians have? Where do we go 

from here with this and how can this committee best stay on top 

of that and continue to work with the VA to make sure that we 

are serving these veterans all across the country? 

And I will bring El Paso up. Obviously one of the challenges is 

that this involves a very case management intensive approach. And 

you are right. The worst case scenario is just to cancel somebody’s 

medication without follow-up because as we all know, that is why 

people are turning to heroin in the streets. 

So how do we get this right and how do we get it right across 

the board in the VA and what is the follow-up? 


VACREP0180 with DISTILLER
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Dr. CLANCY. So what I might suggest is that you invite us back 

for a briefing and we would give you a follow-up. You pick the frequency, a couple of months, three months. 

And I did want to—didn’t get a chance to say before to Congressman O’Rourke that I do have people monitoring for this abrupt discontinuation of medications. And I’m really worried about it when 

people change providers, right? If we’re sending out a message that 

says we want to see fewer veterans on opioids, it’s much, much 

easier when someone changes providers to just say no. That is absolutely not acceptable and that is no definition of success here. So 

I wanted to be very, very clear on this point. 

Some of these challenges are areas where U.S. medicine is struggling in general. Chronic pain in particular and for mental health, 

we’ve had to blaze some trails. There is no clear-cut blood test that 

one can do like a blood sugar or blood pressure, whatever, to double 

check on the diagnosis or assessment. 

It depends a lot on the use of standardized questions in some 

cases. And this we are working very hard on right now. We are 

changing how we schedule appointments and simplifying it so that 

it is much easier to get veterans in for that follow-up assessment. 

But you should hold us accountable and I would look forward to 

showing you where we’ve been and where we’re going. In no way 

do I not want to say that we have problems to solve. We do. We 

own them and we’re stepping up to them and look forward to your 

support. 

Where you can help is helping to work with us on reducing stigma. I mean, this remains a huge, huge problem. And also, I think 

sending a sense that you are supporting the efforts to get better 

care for clinicians—I mean, for veterans. 

One of our challenges is that a lot of young people are not choosing to go into these fields and that is the ultimate recruitment 

problem is that if they’re not—we have terrific incentives thanks 

to the Clay Hunt Act, in terms of debt reduction thanks to the Veterans Choice Act and so forth. And those are great tools, but someone has to actually make the decision to go down that path. 

Ms. KUSTER. Thank you very much. 

Mr. COFFMAN. Thank you, Ranking Member Kuster. 

And, Dr. Clancy, I want to stress again the need for you to turn 

over documents when requested by Congress. And your failure to 

do so makes our job very difficult. 

Mr. O’Rourke, Texas. 

Mr. O’ROURKE. And, Dr. Clancy, thank you for addressing the El 

Paso issue and the larger issue within the VA to ensure that you 

are monitoring those veterans who are going to be coming off of 

opiates. But, again, the feedback stands because I am hearing it directly from veterans that that is apparently not happening in El 

Paso. 

And I think we both must conclude that for every veteran who 

takes the time to come down to a town hall meeting despite whatever they are going through to tell their congressman that they are 

having this problem in front of 200 other veterans and is admitting 

that they are receiving opiates and now are doing without that 

there are many others that that person represents who have just 

given up and says why should I bother. 


VACREP0180 with DISTILLER
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So we have got a problem in El Paso, perhaps nationally in terms 

of ramping people down or finding an alternate therapy to pair 

with their cessation of opiates. 

I would like you to respond to something that we have heard the 

secretary say and read about in the press that he has got 28,000 

positions to fill in the VHA. It is something that Under Secretary 

Sloan Gibson reiterated three weeks ago, four weeks ago in a hearing here. 

And then when the ranking member and I and some other Members of Congress and the Senate were in your command and control 

center on the 8th Floor a few weeks back, we heard that that number was actually not 28,000. It was 50,000 positions to be filled at 

the VHA. 

Could you confirm that number and could you tell me how you 

are prioritizing those hires? And obviously I am getting to if we 

have a crisis in mental health and we are treating all hires the 

same, we have a problem. If you are prioritizing mental health, 

here is a chance to tell this committee and the public at large. 

Dr. CLANCY. So I did not hear the number 50,000, so I’m going 

to have to check on that and get back to you directly I think would 

probably be the easiest way to say that. With 300,000 employees 

sorting out normal turnover which is somewhere around seven or 

eight percent across all the disciplines from, you know, what 

we’re—areas where we’re trying to fill is a little bit challenging. 

We have identified five areas that are the highest priority, physicians, nurses, mental health professionals, physician assistants, 

and I’m blocking on the fifth one, but mental health professionals 

is clearly on that list. And, in fact, we have been way ahead of the 

curve compared to the rest of the country in terms of hiring mental 

health professionals from multiple disciplines. They work as teams. 

We’ve got them in primary care as well as working in mental 

health clinics and so forth. 

Trying to do everything to make it almost impossible to seek assistance and get it. If you actually do get care from one of our facilities, we have a long way to go. I was simply commenting on the 

overall pipeline problem. 

The other area where we are beginning—where we do a lot now 

but I think could do much more is in tele-mental health. So Big 

Spring, Texas which isn’t that far from you in Texas terms, you 

know, they tried very, very hard to recruit psychiatrists and had 

a problem and recently recruited one from Wisconsin who is not 

moving. It—that individual is providing all virtual care. 

So we’re working with them to try to figure out how to make that 

business process work as smoothly as possible. Many veterans prefer that. They find it a bit less confrontational. 

Mr. O’ROURKE. And I appreciate that. And as I yield my time, 

I will just conclude. You have asked for an additional briefing or 

hearing to follow-up. I hope that when you come back, you come 

back with a plan for El Paso or any under-served community. And 

you say you know what, we are paying psychiatrists and psychologists and therapists and social workers and counselors X. I am 

going to pay them X plus 20 percent to get them to El Paso or that 

under-served community and then to retain them once they are 

there because you have a huge problem with retention as well, and 


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that is a suggestion, or some other plan that really treats this as 

the crisis that it is versus the, you know, we are making this a priority. We are going to do this, that, and the other. 

I need dollars on the table, specific offers, deals that will get that 

psychiatrist or mental health professional there in the first place 

and then keep them there after. So I hope to hear specifics next 

time. 

So appreciate your answers to our questions today. 

And, Mr. Chair and Ranking Member, thank you for holding this 

hearing. Really important. Thanks. 

Mr. COFFMAN. Ranking Member Kuster. 

Ms. KUSTER. Thank you, Mr. Chair. 

And just briefly I want to follow-up for my colleague that we will 

do a follow-up hearing and not only on the types of pain management and techniques that do seem to be working but in particular, 

I would like to include tele-mental health. And maybe we could 

even do a short demonstration, but just for you that that might be 

an alternative in this crisis situation that you have. I want to make 

sure that we stay on top of this so that our colleague, his region 

gets served. 

Thank you. 

Mr. COFFMAN. Thank you, Ranking Member Kuster. 

Our thanks to the witnesses. You are now excused. 

Today we have had a chance to hear about problems that exist 

within the Department of Veterans Affairs with regard to prescription management and veteran suicides. This hearing was necessary 

to accomplish a number of items, to demonstrate the lack of care 

and follow-up for veterans prescribed medications for mental disorders, to demonstrate the inaccuracies and discrepancies in the 

data collected by VA regarding veteran suicides and those diagnosed with mental disorders and, three, to allow VA to inform this 

subcommittee what it plans to do to improve these glaring deficiencies in order to ensure veterans are receiving the care they deserve. 

I ask unanimous consent that all members have five legislative 

days to revise and extend their remarks and include extraneous 

materials. Without objection, so ordered. 

I would like to once again thank all of our witnesses and audience members for joining in today’s conversation. 

With that, this hearing is adjourned. 

[Whereupon, at 12:12 p.m., the subcommittee was adjourned.] 


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Æ 


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