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S. HRG. 113–680 

OVERMEDICATION: PROBLEMS AND SOLUTIONS 

HEARING 

BEFORE THE

COMMITTEE ON VETERANS’ AFFAIRS 

UNITED STATES SENATE 

ONE HUNDRED THIRTEENTH CONGRESS 

SECOND SESSION 

APRIL 30, 2014 

Printed for the use of the Committee on Veterans’ Affairs 

( 

Available via the World Wide Web: http://www.fdsys.gov 

(II) 

COMMITTEE ON VETERANS’ AFFAIRS 

BERNARD SANDERS, (I) Vermont, Chairman 

JOHN D. ROCKEFELLER IV, West Virginia 

PATTY MURRAY, Washington 

SHERROD BROWN, Ohio 

JON TESTER, Montana 

MARK BEGICH, Alaska 

RICHARD BLUMENTHAL, Connecticut 

MAZIE HIRONO, Hawaii 

RICHARD BURR, North Carolina, Ranking 

Member 

JOHNNY ISAKSON, Georgia 

MIKE JOHANNS, Nebraska 

JERRY MORAN, Kansas 

JOHN BOOZMAN, Arkansas 

DEAN HELLER, Nevada 

STEVE ROBERTSON, Staff Director 

LUPE WISSEL, Republican Staff Director 

(III) 

C O N T E N T S 

APRIL 30, 2014 

SENATORS 

Page 

Sanders, Hon. Bernard, Chairman, U.S. Senator from Vermont ........................ 1 

Burr, Hon. Richard, Ranking Member, U.S. Senator from North Carolina ....... 3 

Blumenthal, Hon. Richard, U.S. Senator from Connecticut ................................ 5 

Isakson, Hon. Johnny, U.S. Senator from Georgia ............................................... 5 

Begich, Hon. Mark, U.S. Senator from Alaska ..................................................... 53 

WITNESSES 

Petzel, Robert, M.D., Under Secretary for Health, Veterans Health Administration, U.S. Department of Veterans Affairs; accompanied by Tracy 

Gaudet, M.D., Director, Office of Patient Centered Care and Cultural 

Transformation and Peter Marshall, M.D., Director of Primary Care Pain 

Management, Minneapolis VA medical center: .................................................

Impromptu question/answer ............................................................................ 7 

Oral statement .................................................................................................. 8 

Prepared statement .......................................................................................... 9 

Response to posthearing questions submitted by: 

Hon. Bernard Sanders .................................................................................. 19 

Hon. Mark Begich ......................................................................................... 23 

Hon. Richard Blumenthal ............................................................................ 24 

Coots, BG Norvell V., USA, Deputy Commanding General (Support), U.S. 

Army Medical Command and Assistant Surgeon General for Force Projection, Office of the Surgeon General, U.S. Army; accompanied by COL Kevin 

T. Galloway, Director, Army Pain Management Program, Rehabilitation 

and Reintegration Division .................................................................................. 24 

Prepared statement .......................................................................................... 26 

Response to posthearing questions submitted by: 

Hon. Bernard Sanders .................................................................................. 32 

Hon. Richard Blumenthal ............................................................................ 34 

Hon. Mark Begich ......................................................................................... 35 

Briggs, Josephine, M.D., Director, National Center for Complementary and 

Alternative Medicine, National Institutes of Health ........................................ 36 

Prepared statement .......................................................................................... 38 

Response to posthearing questions submitted by: 

Hon. Bernard Sanders .................................................................................. 40 

Hon. Mark Begich ......................................................................................... 42 

Additional information ..................................................................................... 44 

Kahn, Janet, Ph.D., Research Assistant Professor, Department of Psychiatry, 

University of Vermont and Senior Policy Advisor, Consortium of Academic 

Health Centers for Integrative Medicine ........................................................... 60 

Prepared statement .......................................................................................... 63 

Edlund, Mark, M.D., Ph.D., Senior Research Public Health Analyst, Behavioral Health Epidemiology Program, RTI International ................................... 97 

Prepared statement .......................................................................................... 99 

APPENDIX 

American Legion, The; prepared statement .......................................................... 109 

Ilem, Joy J., Deputy National Legislative Director, Disabled American Veterans (DAV); prepared statement ....................................................................... 112 

Page

IV 

Maffucci, Jacqueline A., Ph.D., Research Director, Iraq & Afghanistan Veterans of America (IAVA); prepared statement .................................................. 115 

Citizens Commission on Human Rights International (CCHR); report .............. 117 

(1) 

OVERMEDICATION: PROBLEMS AND 

SOLUTIONS 

WEDNESDAY, APRIL 30, 2014 

U.S. SENATE, COMMITTEE ON VETERANS’ AFFAIRS, Washington, DC. 

The Committee met, pursuant to notice, at 10:05 a.m., in room 

418, Russell Senate Office Building, Hon. Bernard Sanders, Chairman of the Committee, presiding. 

Senators present: Senators Sanders, Rockefeller, Begich, 

Blumenthal, Burr and Isakson. 

OPENING STATEMENT OF HON. BERNARD SANDERS, 

CHAIRMAN, U.S. SENATOR FROM VERMONT 

Chairman SANDERS. Let us get to work. Let me thank our panelists for being with us for a really important discussion about a significant issue. 

Within the veterans’ community—and in fact, throughout our 

Nation both in the public sector and the private sector—we face a 

very serious problem of overmedication. 

The result of that overmedication is significant numbers of people treated in the Department of Defense facilities, VA facilities, 

and in the private sector become dependent upon those medications 

intended to help them and ease their pain. Pain is a huge problem 

in the country and how we treat that pain in the most effective 

way is really what we are discussing today. 

Some people who are treated with a whole lot of medication become addicted, and I think we all know what happens when people 

become addicted, in the worst cases some may end up losing their 

lives due to overdoses. In my State and throughout this country, 

this is a huge problem. 

This is a major issue that has been discussed on this Committee 

during the last year, and we are so glad we have such a distinguished panel with us today to help us examine this problem. 

But, before we get to this issue at hand, I did want to say a very 

brief word about another issue that has attracted a lot of attention 

in this country, and that is the developing situation at the VA medical center in Phoenix. 

As I think everyone in this room knows, some very, very serious 

allegations have been made regarding delays in health care access 

and, as a result, the possible deaths of veterans. I just want to 

make it very very clear that I take and this Committee takes these 

allegations extremely seriously; and we are going to do everything 

we can to get to the bottom of this story and get to the truth. 

2 

Yesterday I spoke to the VA’s acting inspector general, Richard 

Griffin. There is a thorough investigation being conducted by the 

VA IG in Phoenix and I have been assured by Mr. Griffin that he 

has the resources he needs to thoroughly investigate that situation. 

I expect that the inspector general’s office will conduct its investigation thoroughly and provide this Committee with an objective 

analysis of these very serious allegations. And as I indicated the 

other day, it is my intention to hold a hearing on this issue once 

the inspector general’s inquiry is complete. 

I want to make two brief points on this issue. First, we will get 

to the bottom of what has happened in Phoenix. We will reach conclusions based on an objective investigation of the facts, not TV reports but an objective investigation of the facts. 

Second, we should not let these allegations impugn the excellent 

work done throughout this country by hundreds of thousands of VA 

doctors, nurses, administrators, and staff at all levels, many of 

whom are veterans themselves or are closely related to veterans. 

I have been all over this country. I just came back from the VA 

facility in Minneapolis, MN, and my assessment is that we have 

some great people there doing great work. 

Additionally, a recent survey by the American Consumer Satisfaction Index, an independent consumer service survey, pointed out 

patient satisfaction is incredibly high within VA—higher, perhaps, 

than the private sector. And I can tell you in Vermont—and I think 

this story is true all over this country—that when veterans walk 

into the VA, they feel very good about the quality of care they get. 

And I do not want anything that is happening or may have happened in Phoenix to impugn the very good work done by people 

throughout this country. 

Getting back to the issue at hand, as a Nation, we must remember that for many veterans, chronic pain is a part of their daily life. 

According to VA data, the most common diagnosis among post9/11 veterans is musculoskeletal ailments, including joint, neck, 

and back disorders. Chronic pain is a common symptom of this 

cluster of conditions. 

VA research demonstrates greater than 50 percent of male veterans using VA primary care report instances of chronic pain and 

the prevalence of chronic pain may be even higher among women 

veterans. 

Therefore, options for managing chronic pain among our veteran 

population are paramount to improving quality-of-life and reintegration. 

Additionally, PTSD, along with other mental health diagnoses, 

such as depression and anxiety, are frequently diagnosed among 

our veterans. According to the most recent data from VA, more 

than 55 percent of our post-9/11 veterans have been diagnosed with 

some type of mental health disorder. 

Just as with chronic pain, it is critical these veterans receive the 

treatment they need and deserve. Oftentimes, opioids are used to 

treat both chronic pain and certain mental health disorders. While 

opioids can be quite effective in treating these conditions, they also 

come with significant risk which is what we are going to be discussing today. 

3 

Therefore, it is critical that these medications are prescribed to 

the right patients, with careful monitoring and a clear understanding of proper usage. 

I would point out that Senator John Boozman of Arkansas has 

been one of those Senators here who has raised this issue and I 

think, as we all know, John has been in the hospital with a heart 

issue. I think I speak for the whole Committee in wishing him the 

very best of luck and returning to us as soon as possible. 

Senator Burr. 

STATEMENT OF HON. RICHARD BURR, RANKING MEMBER, 

U.S. SENATOR FROM NORTH CAROLINA 

Senator BURR. Well, thank you, Mr. Chairman, and let me report 

for my colleagues that Senator Boozman is home. He did not have 

a heart attack. He had a problem with his aorta. It was not an aneurism. It was a genetic flap that had he not caught it and had 

they not been able to do a surgical graft on his aorta, he would not 

have survived like many Americans. 

But the report is good. He is home. He will be back with us hopefully soon with a few synthetic parts but I think that by all accounts those synthetic parts work every bit as good as the original. 

Mr. Chairman, thank you for this hearing and, as important, 

thank you to our witnesses for being here. 

Since the Chairman has talked about Phoenix, let me just say 

this. This is not the first issue on quality of care that faces the department, and one veteran death related to delays in care is one 

too many. 

I strongly believe that this Committee needs to hold aggressive 

oversight hearings into these issues that the department continues 

to struggle with, including long wait times for specialty care appointments, the misuse of wait lists, and the issues documented in 

the health care inspections conducted by the inspector general 

which, by my count, is now over 50 since January 2013. 

Even with all of these issues being publicly reported or included 

in the reports by the IG, this Committee has yet to hold a single 

oversight hearing on the quality of care veterans are receiving at 

the VA facilities. 

Mr. Chairman, I would fully support and urge you to hold those 

hearings. 

I say as it relates to Phoenix, I think the Chairman is right. Let 

us get as many of the facts as we can and not rely on what is publicly printed. 

But again, I point to the IG investigations from the past and suggest that it is the responsibility of this Committee to respond to 

some of the problems and to work with the VA, Dr. Petzel, as a 

partner. And I have never seen the agency shy away from trying 

to solve those quality of care issues. 

Now, turning to today’s subject matter, the United States is facing an epidemic of prescription drug abuse. That is why it is important that we are here today to conduct oversight over the care of 

veterans who have chronic pain. It is critical that we ensure that 

VA is taking the necessary steps to address the overuse of certain 

medications and the potential risk of misuse and dual prescriptions. 

4 

It has been estimated that as many as 50 percent of male veterans and as high as 75 percent of female veterans—OEF and OIF 

veterans—struggle with pain. 

The prevalence of chronic pain will likely increase as more servicemembers transition into the VA system. These numbers demonstrate the need for VA to provide quality pain management services to ensure veterans with chronic pain are able to live productive 

and healthy lives. 

According to the Centers for Investigative Reporting, between 

2001 and 2012 the number of VA prescriptions within four opiate 

categories—including hydrocodone, oxycodone, methadone, and 

morphine—surged 270 percent. Additionally, during 2012, VA providers wrote more than 6.5 million prescriptions within those opiate categories. 

I found these numbers alarming, in combination with recent 

media reports that describe veterans with known and documented 

drug addictions who were still being prescribed these types of 

medications. 

I would just like to highlight a couple of stories. A veteran with 

PTSD who self-medicated using oxycodone and heroin who later 

struggled to become clean and sober, who is still struggling with 

PTSD and his addiction, now faces a new battle with the VA system which continues to prescribe him opiates even though his electronic health record documents his addiction and the subsequent 

detox provided by VA. 

Another veteran, while still on active duty, says he was injecting 

himself with an anti-inflammatory drug prescribed by military doctors. When he was treated by VA, they only responded to his pain 

by, ‘‘loading him up on narcotics.’’ This veteran goes on to make the 

following statement, ‘‘There were better options to treat my pain, 

and those were not presented to me. The priority was treating me 

the fastest, seemingly least expensive way, and it was the most 

detrimental.’’ 

Now, I am not sure that this is the patient-centered or veterancentric care that we constantly hear VA describing. Even in today’s 

testimony from the Department we will hear, ‘‘care is increasingly 

personalized, proactive and patient driven.’’ 

If these stories reflect what VA believes is personalized, proactive, and patient driven, we have more problems to address than 

just the quality of care and long wait times. 

When it comes to the care we are providing to those who have 

sacrificed so much for our Nation, we cannot afford to get it wrong. 

This Committee needs to hold VA accountable to ensure they are 

providing world-class care. 

Right now, with the media reports and even VA’s own research, 

I am not sure we are. Today VA will describe their policies, directives, and initiatives to ensure opiate therapies are prescribed to 

veterans in a safe manner. It is our obligation to hold VA accountable and to ensure that they are providing the highest standard of 

care to those who are already in the system. 

Mr. Chairman, I thank you for calling this hearing. I look forward to the witnesses’ testimony which will enlighten us and the 

opportunity to follow up with questions. 

Chairman SANDERS. Senator Burr, thank you very much. 

5 

Senator Blumenthal. 

STATEMENT OF HON. RICHARD BLUMENTHAL, 

U.S. SENATOR FROM CONNECTICUT 

Senator BLUMENTAL. Thank you, Mr. Chairman. 

I want to thank our witnesses for being here and for your dedicated and hard work to the service of our veterans and our Nation; 

and thank you, Mr. Chairman and Ranking Member Burr for your 

comments. 

I want to join in expressing my very strong alarm about the reports from Arizona. If true, these reports indicate not only a betrayal of trust but also, very bluntly, violation of our criminal laws 

in shredding documents and obfuscating evidence that is important 

to protect the public trust. 

So, I hope that the inspector general will complete his report as 

quickly as possible to restore that trust and confidence in the integrity of our system. 

I want place in the record, Mr. Chairman, if I may, a request 

that we be informed as to what the time table is for completing 

that investigation because I very much share the Chairman’s concern that this Committee has a obligation separately and independently of the inspector general, which has been articulated by the 

ranking member as well, that we uncover whatever the facts are 

here and make sure that we fulfill our responsibility. And I believe 

that if the inspector general’s investigation lags that we should 

proceed independently. 

I agree that we should make use of the inspector general’s investigation if it proceeds promptly but I think that we should require 

some kind of preliminary report to us as to what the claims are 

and what the preliminary findings are because the reports about 

a secret waiting list, and about neglect of care, and about disregard 

of the responsibility to provide that care are beyond alarming. They 

are truly angering. 

I want to also express my interest and concern about the subject 

matter of this investigation. I have seen in Connecticut, as we have 

around the country, an epidemic of overuse and abuse of these 

powerful pain killers and other prescription drugs. They are not 

only deeply concerning themselves, but they are potentially a gateway to other abuse such as heroin. 

We have seen in Connecticut and Vermont as well, Mr. Chairman, how these prescription drugs can be a gateway to heroin use 

and other drug abuses; and so, particularly when it comes to our 

veterans, we need to make sure that we do whatever possible to 

prevent this kind of overuse and abuse. I know that alternate care, 

which we will discuss today, is integral to that effort. 

Thank you very much, Mr. Chairman. 

Chairman SANDERS. Thank you, Senator Blumenthal. 

Senator Isakson. 

STATEMENT OF HON. JOHNNY ISAKSON, 

U.S. SENATOR FROM GEORGIA 

Senator ISAKSON. Well, Chairman Sanders, thank you for calling 

this hearing. I want to echo the words of Ranking Member Burr, 

6 

yourself, and Senator Blumenthal that the Arizona situation is 

troubling for all of us. 

I am glad we are going to get to the bottom of it. I hope we will 

do so as expeditiously as possible, and then I hope we can take action to help support VA in finding out where there is a problem, 

if there is one, and then correcting it. 

Dr. Petzel and I have become close friends over the last 8 to 9 

months because of incidences that neither one of us wish would 

have happened. His quick response in Atlanta has been greatly appreciated. His response at the VA hospital in Augusta has been 

greatly appreciated, and the fact that he is going to be visiting in 

the next week, I think this weekend, again is very much appreciated and his attention to those matters. 

The VA situation we had in Augusta 2 or 3 years ago: the concern about, sterilization of colonoscopy and endoscopy equipment, 

the difficulty that we had in Atlanta with the suicide situation and 

the postponement or untimely following of mental health patients; 

and now what has happened in Arizona should be a warning call 

for all of us. 

I believe we have 340,000 great employees at VA. They do a tremendous job; and as the Chairman and Ranking Member said, I 

am very proud of what they do. But if there is a growing culture 

that believes it does not matter or it is not as important or our care 

is not as important as we think it should be, we need to nip that 

in the bud and see to it VA is to every veteran and to this country 

what it was promised to and what it must be. 

I think it is important and incumbent upon this Committee to 

get to the bottom, wherever the facts lead us, and to get the leadership of VA to go with us so that hand-in-hand we can correct the 

inequities that are going on. 

My last point is this. Pharmaceutical therapy is a godsend in 

terms of pain, in terms of management of disease and other chronic 

ailments. But it also can interact inappropriately with other drugs 

for other ailments. It can also be overprescribed. It also can mask 

a greater problem, particularly with regard to mental health. 

This is a terribly important hearing today. I am not a person of 

medicine nor a person of science but I am familiar enough with 

what goes on in terms of drug abuse and one drug leading to another, that we cannot allow ourselves to take the easy way out in 

terms of pain management or therapy for our veterans. 

We need to always be looking for the long-term benefit of that 

veteran, not just the short-term easing of pain when we are prescribing the power opiates that we are talking about today. 

Thank you for calling this hearing, Mr. Chairman. 

Chairman SANDERS. Senator Isakson, thank you very much for 

your very apt and important remarks. I agree with virtually everything you said. 

What I want to do now, if it is alright with the Committee, is 

to introduce our panelists, but I did want to give Dr. Petzel a 

minute or two to address concerns about Arizona. I want the main 

focus of this hearing to stay on overmedication while there is interest about what is happening in Arizona. 

Dr. Petzel, could you briefly give us your understanding of the 

situation there? 

7 

Dr. PETZEL. Thank you very much, Chairman Sanders. 

First of all, it is important to state that we do care very deeply 

about the care of every single veteran that we are privileged to 

serve. They have earned and they deserve the absolute highest 

quality care that we can provide. 

We take these allegations, as all of you do, very seriously. That 

is why we have asked the independent office of VA’s IG to go there 

and do an objective, independent, complete review as to exactly 

what has occurred. 

We also sent, from VHA, a team to Phoenix early to review the 

appointment and scheduling processes, and I need to say that todate we found no evidence of a secret list and we have found no 

patients who have died because they have been on a wait list. 

We think it is very important that the inspector general be allowed to finish their investigation before we rush to judgment as 

to what has actually happened in Phoenix. 

The other important point is that when an incident like this occurs, as with colonoscopies and mental health consults that were 

mentioned earlier, we conduct a thorough systemwide look which 

we are in the process of doing now with scheduling and wait lists, 

seeing if the alleged practices are not occurring at any one of our 

other 150 medical centers. 

If the allegations are true, they are absolutely unacceptable and 

we—if the inspector general does confirm and substantiate these 

claims—we are going to take swift and very appropriate action. 

The last point is that the veterans deserve to have full faith in 

their VA health care system. VA facilities are committed to transparency. We undergo multiple external and independent reviews 

and every year we are committed to ensuring our veteran community and the public that VA hospitals are safe and that the quality 

of care there is high. 

Finally, as has been mentioned by several of you, we do appreciate the hard work and the dedication of all of our employees. 

These people are committed to the person to providing, again, the 

best care possible to these veterans who have earned and who deserve that care. 

Thank you. 

Chairman SANDERS. OK. Thank you very much, Dr. Petzel. 

I thought it was important we deal with that issue briefly. Now, 

let us focus on the issue at hand which is overmedication problems 

and solutions. In order to address that issue, we have two excellent 

panels. 

Our first panel will include Dr. Petzel, who is the Under Secretary for Health, Veterans Health Administration, Department of 

Veterans’ Affairs; accompanied by Dr. Tracy Gaudet, who is the Director, Office of Patient Centered Care and Cultural Transformation. Dr. Peter Marshall, Director of Primary Care Pain Management at the Minneapolis VA medical center. 

Brigadier General Norvell V. Coots, Deputy Commanding General, U.S. Army Medical Command and Assistant Surgeon General 

for Force Projection, Office of the Surgeon General; and he is accompanied by Colonel Kevin T. Galloway, Program Director, Army 

Pain Management Program. 

8 

We also have Dr. Josephine Briggs, Director of the National Center for Complementary and Alternative Medicine, National Institutes of Health. 

So, thank you all very much for being with us; and Dr. Petzel, 

you may begin. 

STATEMENT OF ROBERT PETZEL, M.D., UNDER SECRETARY 

FOR HEALTH, VETERANS HEALTH ADMINISTRATION, U.S. 

DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY 

TRACY GAUDET, M.D., DIRECTOR, OFFICE OF PATIENT CENTERED CARE AND CULTURAL TRANSFORMATION AND 

PETER MARSHALL, M.D., DIRECTOR OF PRIMARY CARE PAIN 

MANAGEMENT, MINNEAPOLIS VA MEDICAL CENTER 

Dr. PETZEL. Good morning, Chairman Sanders, Ranking Member 

Burr, and the Members of the Committee. 

I want to thank you for the opportunity to participate in this 

hearing to discuss the Department of Veterans Affairs’ pain management and opioid safety programs, our use of complementary and 

alternative medicine, and psychotropic drug safety. I am accompanied today by Dr. Gaudet as was mentioned earlier and by Dr. 

Peter Marshall. 

Before I begin, I want to express my joy at hearing that Senator 

Boozman is recuperating well. We wish him a speedy recovery and 

look forward to him participating again in the affairs of this 

Committee. 

Let me begin today by acknowledging all of our Nation’s veterans 

who suffer from chronic and acute pain. The burden of pain on veterans is considerable. Studies say that more that 50 percent of all 

veterans receiving care at the VA are affected by some type of 

chronic pain, much of it being musculoskeletal. 

Six elements of effective pain control include the safe and effective use of pain care to enhance the quality of life and the satisfaction of veterans that are living with chronic pain. 

VA’s concept of safe and effective pain care follow these six essential elements. Education of veterans and family members about 

good pain care. Education of the treatment teams about good pain 

care. Developing non-pharmacological and self-management approaches. Safe and evidence-based use of all interventions and 

medications including opioids. Developing effective modalities for 

bringing pain care, especially expertise, to the veteran when needed. And finally, monitoring pain care efficacy at both the individual 

veteran level and at the system level. 

VA recently developed and implemented an innovative opioid 

safety program. This program uniquely combines feedback to providers at facilities on their prescribing practices with education and 

training to ensure opioid pain medications are used safely, effectively, and judiciously across our entire system. 

The purpose of the initiative is to help ensure that pain management is addressed thoughtfully, compassionately, and safely. This 

initiative holds considerable promise for mitigating the risks of 

harm among veterans receiving long-term opioid therapy, for promoting provider competence and safe prescribing of opioids, and in 

promoting veteran-centered, evidence-based, coordinated, disciplined, multi-disciplinary pain care for chronic pain. 

9 

For cases where veterans have developed problems with opioid 

abuse and addiction, VA offers effective evidence-based treatments 

for opioid use disorder. Intensive treatments consisting of options 

for evidence-based psychotherapy and effective pharmacological 

therapy for opioid use disorder is available at all of our VA medical 

centers to help facilitate veterans’ recovery. 

Recognizing that psycho-pharmacological treatments for mental 

health conditions require on-going efforts in quality improvement, 

VA is implementing a psychosocial drug safety initiative. 

It addresses pharmacological treatments across the range of 

mental health conditions including PTSD, depression, schizophrenia, bipolar disorder, substance abuse disorder, and many 

other mental health conditions. 

This psychotropic drug initiative is designed to identify overuse, 

underuse, and inappropriate use of these drugs by reviewing provider prescribing habits, patient use, and providing feedback to 

providers about their use of these medications and education about 

the appropriate use when we do find that the use is inappropriate. 

Key leadership has identified as its number 1 strategic goal to 

provide veteran patients with personalized, proactive, patient-driven health care. This approach to health prioritizes the veteran and 

their values and partners with them to personalize the strategies 

to optimize their health, healing, and sense of well-being. 

Many of the strategies that may be of benefit extend beyond 

what we conventionally address or provide by the health care system. Integrative medicine, which includes complementary and alternative medicine, provides a framework that aligns with this goal 

of personalized, proactive, patient-drive care. 

There is a growing evidence for the effectiveness of non-pharmacological approaches as part of a comprehensive plan for chronic 

pain. These include acupuncture, massage, chiropractic care, mindfulness meditation, exercise therapy, relaxation therapies, and 

yoga. These are all being increasingly made available to our veteran patients. 

Mr. Chairman, we know our work to improve veteran care 

through accessible, safe, and effective pain management service is 

an ongoing task and is not yet finished. 

However, we are confident that we are developing and implementing programs that are responsive to veteran needs. We appreciate your support in identifying and resolving these challenges as 

we find new ways to care for America’s veterans. 

Mr. Chairman, this concludes my testimony. My colleagues and 

I are prepared to answer your questions. 

[The prepared statement of Dr. Petzel follows:] 

PREPARED STATEMENT OF DR. ROBERT PETZEL, UNDER SECRETARY FOR HEALTH, 

VETERANS HEALTH ADMINISTRATION (VHA), U.S. DEPARTMENT OF VETERANS

AFFAIRS

Good morning, Chairman Sanders, Ranking Member Burr, and Members of the 

Committee. Thank you for the opportunity to participate in this hearing and to discuss the Department of Veterans Affairs’ (VA) pain management programs and the 

use of complementary and alternative medicine. I am accompanied today by Dr. 

Tracy Gaudet, Director of Office of Patient Centered Care & Cultural Transformation, and Dr. Peter Marshall, Director of Primary Care Pain Management. 

The challenges related to living with chronic pain and providing safe and effective 

pain care are by no means unique to Veterans and the VA health care system. As 

10 

1 Institute of Medicine. 2011. Relieving Pain in America: A Blueprint for Transforming Pain 

Prevention, Care, Education and Research. Washington, DC: The National Academies Press. 2Gironda, R.J., Clark, M.E., Massengale, J.P., & Walker, R.L. (2006).. Pain among Veterans 

of Operations Enduring Freedom and Iraqi Freedom. Pain Medicine, 7, 339–343. 3 Veterans Health Administration (2013). Analysis of VA health care utilization among Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn 

(OND) Veterans. Washington, DC: Department of Veterans Affairs. 4Lew, H.L., Otis, J.D., Tun, C., Kerns, R.D., Clark, M.E., & Cifu, D.X. (2009). Prevalence of 

chronic pain, Post Traumatic Stress Disorder, and post-concussive syndrome in OEF/OIF veterans: The polytrauma clinical triad. Journal of Rehabilitation Research and Development, 46, 697–702. 5See citations 3 and 4. 

described in the 2011 Institute of Medicine (IOM) report, ‘‘Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research,’’ 1

pain is a public health challenge that affects millions of Americans and is increasing 

in prevalence. Pain contributes to morbidity, mortality, and disability across our Nation and the costs of pain can be measured both in terms of human suffering as 

well as economic impact. The IOM estimated that chronic pain alone affects 100 million United States citizens and that the cost of pain in the United States is at least 

$560–$635 billion each year, which is the combined cost of lost productivity and the 

incremental cost of health care. 

CHRONIC PAIN IN VETERANS

The burden of pain on the Veteran population is considerable. We know that Veterans have much higher rates of chronic pain than the general population, with 

more than 50 percent of all Veterans enrolled and receiving care at VA affected by 

chronic pain.2 Chronic pain is the most common medical problem in Veterans returning from the last decade of conflict (almost 60 percent).3 Many of these Veterans 

have survived serious and at times catastrophic injuries frequently a result of roadside bombs and other blast injuries. These events can result in multiple physical 

traumas including amputations and spinal cord injuries as well as concomitant psychological trauma which can compound chronic pain concerns. Often these Veterans 

require a combination of strategies for the effective management of pain, which may 

include treatment with opioid analgesics. That makes pain management a very important clinical issue for VA. Further, the treatment of pain is highly complex, and 

in the recent past, health care providers have often been accused of undertreating 

the pain that patients suffer. Getting the balance right is a challenge that we continue to work toward. 

In 2010, VA and the Department of Defense (DOD) published evidence-based Clinical Practice Guidelines for the use of chronic opioid therapy in chronic pain. The 

guidelines reserve the use of chronic opioids for patients with moderate to severe 

pain who have not responded to, or responded only partially to, clinically indicated, 

evidence-based pain management strategies of lower risk, and who also may benefit 

from a trial of opioids to improve pain control in the service of improving function 

and quality of life. 

We also know that the long-term use of opioids is associated with significant 

risks, and can complicate health care for Veterans with Posttraumatic Stress Disorder (PTSD), depression, Traumatic Brain Injury (TBI) and family stress—all common in Veterans returning from the battlefield, and in Veterans with substance use 

disorders. Chronic pain in Veterans is often accompanied by co-morbid mental 

health conditions (up to 50 percent in some cohorts) caused by the psychological 

trauma of war, as well as neurological disorders, such as TBI caused by blast and 

concussion injuries. In fact, one study documented that more that 40 percent of Veterans admitted to a polytrauma unit in VHA suffered all three conditions together— 

chronic pain, PTSD, and post-concussive syndrome.4

In addition to these newly injured Veterans suffering from chronic pain conditions 

and neuropsychological conditions, VA cares for millions of Veterans from prior conflicts, who along with chronic pain and psychological conditions resulting from their 

earlier combat experiences, are now developing health concerns related to aging, 

such as cancer, neuropathies, spinal disease, and arthritis, all of which may be accompanied by chronic and at times debilitating pain. All of these Veterans deserve 

safe and effective pain care that may include the use of opioid analgesics when clinically appropriate. 

Thus, VA cares for a population that suffers much higher rates of chronic pain 

than the civilian population, and also experiences much higher rates of comorbidities (PTSD, depression, TBI) and socioeconomic dynamics (family stress, disability, joblessness) that contribute to the complexity and challenges of pain management with opioids.5 So even as more Veterans have the kind of severe and disVerDate Mar 15 2010 19:16 Jul 24, 2015 Jkt 000000 PO 00000 Frm 00014 Fmt 6633 Sfmt 6621 Z:\ACTIVE\043014.TXT PAULIN
11 

6Diversion is the use of prescription drugs for recreational purposes. 

7The overall objective of the national strategy is to develop a comprehensive, multicultural, 

integrated, system-wide approach pain management that reduces pain and suffering and improves quality of life for Veterans experiencing acute and chronic pain associated with a wide 

range of injuries and illnesses, including terminal illness. 8www.va.gov/vhapublications/viewpublication.asp?pub_id=2781 9The term ‘‘facilities’’ or ‘‘facility’’ refers to VA’s 151 medical centers, hospitals, or health care 

systems. 

abling pain conditions that require stronger treatments such as opioids, so do more 

of them have increased risk for overdose complicated by depression, PTSD and substance use disorders. 

In recognition of the seriousness of the impact of chronic pain on our Veterans’ 

health and quality of life, VHA was among one of the first health systems in the 

country to establish a robust policy on chronic pain management and to implement 

a system-wide approach to addressing the risks of opioid analgesia. 

I would like to at this time outline our approach to this pain care transformation. 

I will highlight VA’s current pain management strategies as well as actions being 

taken to improve the management of chronic pain, including the safe use of opioid 

analgesics, the prevalence and use of opioid therapy to manage chronic pain in high 

risk Veterans, the challenges of prescription drug diversion 6 and substance use disorders among Veterans, and efforts being made to broaden non-pharmacological approaches to pain care. I will also describe some of the best pain care practices across 

the VA health care system. 

VA’S PAIN CARE MISSION

VA’s mission relative to pain care is simple: safe and effective pain care to enhance the quality of life and satisfaction of all Veterans living with chronic pain. 

VA’s concept of safe and effective pain care includes the following six essential elements: 

1. Education of Veterans and family members about good pain care; 

2. Education of the treatment teams about good pain care; 

3. Developing non-pharmacological and self-management approaches; 

4. Safe and evidence-based use of all interventions and medications, including 

opioids; 

5. Developing effective modalities for bringing pain care specialty expertise to the 

Veteran; and 

6. Monitoring pain care efficacy at the individual and system level. 

As a blueprint for implementing these principles throughout the system,7 VHA 

Pain Management Directive 2009–053 8 was published in October 2009 to provide 

uniform guidelines and procedures for providing pain management care. These include standards for pain assessment and treatment, including use of opioid therapy 

when clinically appropriate, for evaluation of outcomes and quality of pain management, and for clinician competence and expertise in pain management. Since publication of the Pain Management Directive, a dissemination and implementation plan 

has been enacted that supports the following: 

• Comprehensive staffing and training plans for providers and staff; 

• Comprehensive patient/family education plans to empower Veterans in pain 

management; 

• Development of new tools and resources to support the pain management strategy; and 

• Enhanced efforts to strengthen communication between VA’s Central Office 

(VACO) and leadership from facilities 9 and Veterans Integrated Service Networks 

(VISN). 

Following the guidance of the VHA National Pain Management Strategy, and in 

compliance with generally accepted pain management standards of care, the Directive provides policy and procedures for the improvement of pain management 

through implementation of the Stepped Care Model for Pain Management (SCMPM), the single standard of pain care for VHA, central to ensuring Veterans receive 

appropriate pain management services. The Directive also requires tracking opioid 

use and implementing strong practices in risk management to improve Veterans’ 

safety. 

To establish the six essential elements of good pain care listed above, numerous 

modalities have been recently implemented or are in the process of implementation 

throughout the VHA, including: pain schools, tele-pain schools, apps and web based 

modules for patient and family education; case based audio conferences, Rural 

Health Initiative and VeHU trainings, Nation-wide community of practice calls and 

12 

numerous other training initiatives to educate and train teams; developing Cognitive Behavioral Therapy (CBT) in primary care, tele-CBT, self-management strategies and complementary and integrative medicine modalities; a number of initiatives to address opioid prescribing which I will discuss shortly; e-consultation, Specialty Care Access Network-Extension for Community Healthcare Outcomes (SCANECHO), and telemedicine to bring pain care expertise to all settings; and pain dashboards to monitor care at the individual and populations levels. 

VA facilities are now increasingly leveraging their video conferencing capabilities 

to reach Veterans in the community based outpatient clinics (CBOC) both rural and 

highly rural to provide group and individual visits for pain schools, evidence based 

CBT, smoking cessation, and weight loss through the MOVE program all important 

for the self-care and self-management skills needed as part of a chronic pain care 

plan. 

A particularly exciting initiative is the development of a pain management application for smart phones that will be used by Veterans and their care partners to 

develop pain self-management skills. This tool, called VA Pain Coach, will eventually interface with VHA’s Electronic Health Record (EHR), with appropriate privacy 

protections, allowing Veteran-reported information about pain, functioning, and 

other key elements in a secure mobile application environment to be securely stored 

and accessible to clinicians. VA Pain Coach, which is part of a suite of VA applications called ‘‘Clinic in Hand,’’ has just finished a one-year pilot test phase with 1150 

Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn Veterans and their caregivers and is now being converted to HTML 5 and will be available for smart phones, tablets and as a web based application. In the future, a complementary initiative will build a clinician-facing application that will enhance the 

capacity of clinicians and Veterans to share in monitoring, decisionmaking, treatment planning, and reassessment of pain management interventions. 

THE PATIENT ALIGNED CARE TEAM (PACT): THE CORE OF THE STEPPED CARE MODEL

The VA approach to pain care mirrors its approaches to all health care concerns: 

care is increasingly personalized, proactive and patient driven. Chronic pain, as is 

the case with all chronic health conditions, is most safely and effectively addressed 

using a biopsychosocial model in which all aspect of the Veterans health and wellbeing are included in both the assessment and management of the condition: physical health, psychological health and social health. The basic platform for providing 

such care is the Veteran’s PACT, or patient aligned care team, supported by pain 

and other specialists. PACT is a partnership between the Veteran and the health 

care team, which emphasizes prevention, health promotion, and self-management. 

Veterans are the center of the care team and the PACT teamlet, which includes at 

its core a primary care provider, nurse care manager, clinical associate, and clerical 

associate. Core pain teams in PACT often add a behavioral health clinician and 

pharmacist to help address the complexity of pain management. 

THE PAIN MEDICINE SPECIALTY TEAM: SPECIALTY CARE ACCESS SUPPORTING PACT

PACT access to consultation and collaborative care with interdisciplinary pain 

specialty teams is critical. VHA’s Pain Medicine Specialty Team Workgroup, chartered on January 26, 2012, provides standards for pain specialty care services and 

support of PACT pain management in the Stepped Care Model. Key areas of focus 

include the development of collaborative care models and participation in provider 

and team education through telehealth, e-consults, and SCAN-ECHO. VA SCANECHO pain experts provide didactics and case-based learning to PACT members 

using videoconferencing technologies to strengthen the competencies of providers in 

pain management. More than 95 percent of VHA facilities have specialty pain clinics with documented yearly increases in use and capacity. 

VHA PAIN MANAGEMENT CENTERS: DEVELOPING AND PROMULGATING

STRONG PRACTICES

The complexity of managing chronic pain may require a more intensive and structured approach to care than can be provided in the primary care or specialty pain 

medicine clinics. To address the need for tertiary care pain services, on December 15, 2010, the VHA charted the Interdisciplinary Pain Management Workgroup 

to assist Veterans Integrated Service Network (VISN) Directors in determining the 

need for tertiary pain care and pain rehabilitation services. As of January 2014, VA 

has ten sites in seven VISNs with Commission on Accreditation of Rehabilitation 

Facilities (CARF)-accredited tertiary care pain rehabilitation programs, an increase 

from only 2 programs in 2009, with 11 more sites in active preparation or actually 

applying for CARF status. These Centers have the capacity for providing advanced 

13 

pain medicine diagnostics, surgical and interventional procedures, and in addition 

provide intensive, integrated chronic pain rehabilitation for Veterans with complex, 

co-morbid, or treatment refractory conditions. 

VHA is in process of greatly expanding access to such Chronic Pain Rehabilitation 

Centers. Pursuant to the expectation that every VISN shall have at least one CARFaccredited tertiary, interdisciplinary pain care program no later than September 30, 

2014, the long-standing CARF Center at the James Haley Veterans Hospital in 

Tampa, one of only two multidisciplinary pain management centers that has been 

twice recognized by the American Pain Society as a Clinical Center of Excellence 

(the other being a program at Stanford University), has provided direct training to 

VISN teams from across VHA who wish to start CARF programs. Some VISNs may 

eventually have 2 or more such programs. In addition, there is an ongoing systemwide education effort, using the expertise at these Centers and in other facilities, 

to educate physicians in Primary Care PACT and other providers taking care of Veterans with chronic pain conditions about Chronic Pain Rehabilitation approaches. 

IMPLEMENTING THE STEPPED CARE MODEL IN VHA

To help manage the implementation of the Stepped Care Model, VHA’s National 

Pain Management Program Office (NPMPO) works closely with other VHA national 

offices such as pharmacy, mental health, and primary care. Other collaborations include NPMPO’s partnership with Women’s Health Services to develop a strategic 

plan to strengthen the capacity for women Veteran pain management services. 

NPMPO also relies on consultation with the interdisciplinary National Pain Management Strategy Coordinating Committee, consisting of members of all relevant 

clinical offices/programs in VHA, and meets regularly with all VISN Pain Points of 

Contact (POC). VISN POCs in turn meet regularly with Facility POCs in their 

VISN. 

The role of the Pain POCs, at the VISN and at the facility level, is primarily to 

coordinate efforts in regard to pain management from an administrative side. The 

Pain POCs are expected to work closely with the Pain specialists at each facility 

within the facility Pain Management Committee. This structure creates a two-way 

communication of successful ‘best practices’ in the field, which are then communicated nationally, as well as advice and support on policy implementation. The 

Pain POCs are not the point of contact for clinical issues regarding individual patients. With regards to evaluation and treatment, a Veteran’s clinical point of contact for their individual pain needs is their primary care provider within the PACT. 

As necessary, the pain medicine specialty team at the facility would work in collaboration. 

STEPPED CARE MODEL FOR PAIN MANAGEMENT

As mentioned earlier, SCM-PM is the single standard of pain care for VHA to ensure Veterans receive appropriate pain management services. Specifically, SCM-PM 

provides for assessment and management of pain conditions in the primary care setting. This is supported by timely access to secondary consultation from pain medicine, behavioral health, physical medicine and rehabilitation, specialty consultation, 

and care by coordination with palliative care, tertiary care, advanced diagnostic and 

medical management, and rehabilitation services for complex cases involving comorbidities such as mental health disorders and TBI. 

In FY 2012, VHA made several important investments in implementing the SCMPM. Major transformational initiatives support the objectives of building capacity 

for enhanced pain management in the primary care setting, including education of 

Veterans and caregivers in self-management, as well as promoting equitable and 

timely access to specialty pain care services. 

There are other important efforts contributing to the implementation of SCM-PM 

in VHA facilities. Current initiatives focus on empowering Veterans in their pain 

management, and expanding capacity for Veterans to receive evidence-based psychological services as a component of a comprehensive and integrated plan for pain 

management. For example, during FY 2012, the VHA National Telemental Health 

Center expanded its capacity to deliver face-to-face, psychological services to Veterans remotely via high-speed videoconferencing links. This initiative not only emphasizes the delivery of cognitive behavior therapy for Veterans with chronic pain, 

but also promotes pain self-management, leading to reductions in pain and improvements in physical functioning and emotional well-being. 

Additionally, a Primary Care and Pain Management Task Force is developing a 

comprehensive strategic and tactical plan for promoting full implementation of the 

SCM-PM in the Primary Care setting, and it continues to work on several products 

in support of this effort. For instance, the Task Force is continuing to expand its 

14 

10The Biopsychosocial Model takes the position that the causes and outcomes of many illnesses often involve the interaction of physical and pathophysiologic factors, psychological traits 

and states, and social-environmental factors. Effective treatment planning accounts for the salience of these factors in the precipitation and perpetuation of illness and illness-related disability. 

network of facility- level Primary Care Pain Management points of contact (Pain 

Champions) who meet monthly, via teleconference, to identity and share strong 

practices that have led to improved pain care in primary care settings. 

VA’s pain management initiatives are designed to optimize timely sharing of new 

policies and guidance related to pain management standards of care. Of particular 

importance are VHA’s continuing efforts to promote safe and effective use of opioid 

therapy for pain management, particularly those initiatives designed to mitigate 

risk for prescription pain medication misuse, abuse, addiction, and diversion. 

OPIOID PRESCRIBING

While opioid medications, due to their high risk to benefit ratio in chronic pain, 

will be playing a less prominent role in chronic pain management in the future, they 

are a primary focus currently due to the attendant risk of their use, particularly 

in individuals with some of the co-morbid conditions mentioned above. 

To monitor the use of opioids by patients in the VA health care system, VA tracks 

multi-drug therapy for pain in patients receiving chronic or long-acting opioid therapy for safety and effectiveness. This includes tracking of use of guideline recommended medications for chronic pain (i.e., certain anticonvulsants, tricyclic 

antidepressants (TCA), and serotonin and norepinephrine reuptake inhibitors 

(SNRI) which have been shown to be effective for treatment of some chronic pain 

conditions), and tracking of concurrent prescribing of opioids and certain sedative 

medications (e.g., benzodiazepines and barbiturates) which can contribute to over sedation and overdose risk when taken with opioids and the other medications for 

pain listed above. 

The prevalence of Veterans using opioids has been measured for Veterans using 

VHA health care services. For FY 2012, of the 5,779,668 patients seen in VA, 

433,136 (7.5 percent) received prescriptions for more than 90 days supply of shortacting opioid medications and 92,297 (1.6 percent) received at least one prescription 

for a long-acting opioid medication in the year. Thus, since more than 50 percent 

of Veterans enrolled in VHA suffer from chronic pain, the most common condition 

in all Veterans, a relatively small percentage of those Veterans are receiving chronic 

opioid therapy, consistent with the DOD/VA Clinical Practice Guidelines which limit 

their use to patients with moderate to severe persistent pain that has not responded 

to other safer alternatives that are clinically appropriate. Of these 525,433 patients 

that received chronic or long-acting opioid therapy, 79,025 (15 percent) were also 

prescribed a TCA, 90,066 (17 percent) were also prescribed an SNRI, and 178,361 

(34 percent) were also prescribed an anticonvulsant some time in FY 2012. 

The co-prescription of either TCAs and SNRIs with opioids is first line therapy 

for the more severe cases of pain related to nerve damage from disease (e.g., diabetes, cancer) or from injuries (e.g., battlefield blast and projectile injuries with or 

without limb amputation and spinal cord injury). The numbers above suggest that 

clinical teams are using medically indicated combinations of medications that are 

specifically needed for these more severe conditions, which themselves are often comorbid with musculoskeletal pain such as injuries to joints, spine and muscles. Of 

note, these prescriptions may or may not have overlapped with the opioid prescription during the year. 

Notably, 272,719 (52 percent) of patients on chronic or long-acting opioid therapy 

received non-medication-based rehabilitative treatments as part of their treatment 

plan (e.g., physical therapy (32 percent), chiropractic care (1 percent), programs to 

encourage physical activity (9 percent) or occupational therapy (17 percent), and 

241,465 (46 percent) also received behavioral or psychosocial treatment for chronic 

pain or co-morbid mental health conditions. 

These data, showing the use of non-medication treatments, suggest that Veterans 

are benefiting from VHA’s efforts to create access to additional pain treatment modalities besides medication. This is consistent with VA’s commitment to transform 

pain care to a biopsychosocial model 10 that addresses all the factors that by research are demonstrated to affect Veterans’ success in chronic pain treatment. Pursuant to this aim, a multimodality, team-based, stepped care model, per VHA Directive 2009–053, is being implemented widely throughout VHA, and in coordination 

with DOD. 

Opioid analgesics may help many patients manage their severe pain when other 

medications and modalities are ineffective or are only partially effective. However, 

15 

there may be risks to both individual patients as well as to the surrounding community when these agents are not prescribed or used appropriately. VA has embarked 

on a two-pronged approach to addressing the challenge of prescription drug diversion and substance use disorders among Veteran patients. One approach is to improve the education and training in pain management and safe opioid prescribing 

for clinicians and the interdisciplinary teams that provide pain management care 

for Veterans. A complementary approach involves improving risk management 

through two systems initiatives. 

OPIOID SAFETY INITIATIVE

VA recently developed and implemented an Opioid Safety Initiative (OSI) program to ensure opioid pain medications are used safely, effectively and judiciously. 

The Opioid Safety Initiative Requirements were issued to the VISN’s on April 2, 

2014. The purpose of the initiative is to ensure pain management is addressed 

thoughtfully, compassionately and safely. The nine goals are summarized below: 

• Goal One: Educate prescribers of opioid medication regarding effective use of 

urine drug screening 

• Goal Two: Increase the use of urine drug screening 

• Goal Three: Facilitate use of state prescription databases 

• Goal Four: Establish safe and effective tapering programs for the combination 

of benzodiazepines and opioids 

• Goal Five: Develop tools to identify higher risk patients 

• Goal Six: Improve prescribing practices around long-acting opioid formulations 

• Goal Seven: Review treatment plans for patients on high doses of opioids 

• Goal Eight: Offer Complementary and Alternative Medicine (CAM) modalities 

for chronic pain at all facilities 

• Goal Nine: Develop new models of mental health and primary care collaboration 

to manage opioid and benzodiazepine prescribing in patients with chronic pain 

To do this, the initiative leverages the VHA’s Electronic Health Record, making 

visible the totality of opioid use at all levels, patient, provider and facility, in order 

to identify high-risk situations. The OSI includes key clinical indicators such as the 

number of unique pharmacy patients dispensed an opioid, unique patients on longterm opioids who receive a urine drug screen, the number of patients receiving an 

opioid and a benzodiazepine (which puts them at a higher risk of adverse events) 

and the average dosage per day of opioids such as hydromorphone, methadone, morphine, oxycodone, and oxymorphone. Patients at risk for adverse events from use 

of opioids are identified through the use of administrative and clinical databases 

using pre-determined parameters based on published evidence and expert opinion. 

Providers whose prescribing practices are not aligned with medical evidence/strong 

practices are provided with counseling, education and support for to improve their 

care of Veterans with pain. Several aspects to measure the implementation of the 

Opioid Safety Initiative upon opioid use were underway at the time of the October 10, 2013 hearing and suggested positive impacts: 

• Despite an increase in the number of Veterans who were dispensed any medication from a VA pharmacy, (i.e., all pharmacy users) in October 2012 compared to 

November 2013, 39,088 fewer Veterans received an opioid prescription from VA during that time period. 

• Performing urine drug screens is a useful tool to assist in the clinical management of patients receiving long-term opioid therapy. As of November 2013, urine 

drug screens were performed on 80,294 more patients than in October 2012. 

• Whenever clinically feasible, the concomitant use of opioid and benzodiazepine 

medications should be avoided. In November 2013, 9,609 fewer patients were receiving these drugs at the same time than in October 2012. 

• Last, the average dose of selected opioids has begun to decline slightly in VA, 

demonstrating that prescribing and consumption behaviors are changing. 

While these changes may appear to be modest given the size of the VA patient 

population, they signal an important trend in VA’s use of opioids. VA expects this 

trend to continue as it renews its efforts to promote safe and effective pharmacologic 

and non-pharmacologic pain management therapies. Very effective programs yielding significant results have been identified (e.g. Minneapolis, Tampa, Columbus), 

and are being studied as strong practice leaders. 

The second system-wide risk management approach to support the Veterans’ and 

public’s safety is promulgation of new regulations that enable VHA to participate 

in state Prescription Drug Monitoring Programs (PDMPs). VA providers can now access the state PDMP for information on prescribing and dispensing of controlled 

substances to Veterans outside the VA health care system. Participation in PDMPs 

16 

will enable providers to identify patients who have received non-VA prescriptions 

for controlled substances, which in turn offers greater opportunity to discuss the effectiveness of these non-VA prescriptions in treating their pain or symptoms. More 

importantly, information that can be gathered through these programs will help 

both VA and non-VA providers to prevent harm to patients that could occur if the 

provider was unaware that a controlled substance medication had been prescribed 

elsewhere already. 

LEVERAGING STRONG PRACTICES TO CHANGE OPIOID PRESCRIBING: THE MINNEAPOLIS VA MEDICAL CENTER (VAMC)

In summary, there is growing evidence of the successful implementation of a 

Stepped Care Model for Pain Management in VHA. Importantly, Veterans receiving 

long term opioid therapy for management of chronic pain are increasingly likely to 

be receiving this therapy in the context of multidisciplinary and multimodal care 

that often incorporates physical and occupational therapy and mental health services. All VISNs provide specialty pain clinic services, and the number of Veterans 

who receive these services has grown steadily for the past five years. Ten facilities 

now provide CARF accredited pain rehabilitation services, a rapid increase in the 

availability of these higher specialized pain rehabilitation services for our most complex Veterans with debilitating chronic pain and comorbid mental health disorders. 

VA learns from VISNs and VAMCs that are early adopters of implementing evidence-based guidelines and best practices. The Minneapolis VAMC has had great 

success with decreasing over utilization of opioid pain medications and developing 

a full range of pain management services. These efforts began with the Minneapolis 

VA Opioid Safety Initiative in 2011. Strong medical center leadership support led 

to the development of systems to identify patients on high risk opioids and provide 

team-based support from pharmacy, primary care, and mental health to develop individualized care plans to decrease high risk opioid use and improve patient safety. 

Implementing this best practices approach, Minneapolis has seen a nearly 70 percent decrease in high-dose opioid prescribing for chronic non-cancer pain patients. 

This early success lead to a coordinated effort between Minneapolis VAMC and 

VISN 23 to expand support for PACT team-based pain management, Step 2 pain 

consultation services, and rehabilitation focused multidisciplinary pain specialty 

services. The Minneapolis pain specialty services are now developing state-of-theart, evidence-based interdisciplinary pain management programs and services, and 

also providing leadership, guidance, and support for primary care pain management 

throughout VISN 23 and VHA. 

VA is working aggressively to promote the safe and effective use of long-term 

opioid therapy for Veterans with chronic pain for whom this important therapy is 

indicated. VA’s Opioid Safety Initiative holds considerable promise for mitigating 

risk for harms among Veterans receiving this therapy, for promoting provider competence in safe prescribing of opioids, and in promoting Veteran-centered, evidencebased, and coordinated multidisciplinary pain care for Veterans with chronic pain. 

VA’s Opioid Safety Initiative Tool provides monthly reports to all VISNs and facilities as to overall opioid prescribing an average dose per day of opioid therapy, which 

informs facilities of Veterans who are at risk for adverse outcomes and enables remedial steps to reduce those risks as described earlier by the Minneapolis VAMC. 

Interventions include VISN level, facility level and committees that provide support 

and education to improve the appropriate opioid risk mitigation for individual providers and facilities. Early evidence of success in reducing overall opioid prescribing 

and average dose per day of opioid therapy is encouraging. 

COMPLEMENTARY AND INTEGRATIVE MEDICINE

VHA leadership has identified as its number one strategic goal ‘‘to provide Veterans personalized, proactive, patient-driven health care.’’ Integrative Health (IH), 

which includes CAM approaches, provides a framework that aligns with personalized, proactive, patient-driven care. There is growing evidence for effectiveness of 

non-pharmacological approaches as part of a comprehensive care plan for chronic 

pain which includes acupuncture, massage, yoga and spinal manipulation. These are 

all being increasingly made available to Veterans. 

In 2011, VA’s Healthcare Analysis and Information Group published a report on 

Complementary and Alternative Medicine in VA. At that time, 89 percent of VHA 

facilities offered some form of CAM/IH; however, there was extensive variability regarding the degree, level, and spectrum of services being offered in VHA. The top 

reasons for offering CAM/IH included the following: 

• Promotion of wellness; 

• Patient preferences; and 

17 

• Adjunct to chronic disease management. 

The most commonly offered CAM/IH modalities in VHA facilities were: Meditation, 

Stress Management/Relaxation Therapy, Progressive Muscle Relaxation, Biofeedback, and Guided Imagery. The conditions most commonly treated with CAM/IH include: Stress management, Anxiety Disorders, PTSD, Depression, and Back Pain. 

In VA, chiropractic care is part of the standard medical benefits and is administratively aligned under Rehabilitation and Prosthetic Services. The number of Veterans receiving chiropractic services in VA has expanded form under 4,000 in FY 

2004, to over 26,000 in FY 2013. In addition to clinical services, Rehabilitation and 

Prosthetic Services is working to develop innovative approaches to foster chiropractic inter-professional education strategies and research projects. 

VA recognizes the importance and benefits of recreational therapy in the rehabilitation of Veterans with disabilities. Currently, over 30 VA medical centers across 

the country participate in therapeutic riding programs. These programs use equine 

assisted therapeutic activities to promote healing and rehabilitation of Veterans 

with a variety of disabilities and medical conditions (e.g. Traumatic Brain Injury, 

polytrauma). VA facilities participating in such programs utilize their locally appropriated funds to support their participation. Facilities can also request supplemental 

support through the VA Secretary’s General Post Fund, a trust fund administered 

by the Department to support a variety of recreational and religious projects and 

national rehabilitation special events. 

A monthly Integrative Health (IH) community of practice conference call provides 

VHA facilities national updates, strong practices, and new developments in the field 

and research findings related to IH. 

A key development is a Joint Incentive Fund DOD/VA project to improve Veterans’ and Servicemembers’ access to CAM, the ‘‘Tiered Acupuncture Training 

Across Clinical Settings’’ (ATACS) project. ATACS represents VHA’s initiative to 

make evidence-based complementary and alternative medicine therapies widely 

available to our Veterans throughout VHA. A VHA and DOD network of medical 

acupuncturists are being identified and trained in Battlefield (auricular) Acupuncture by regional training conferences organized jointly by VHA and DOD. The goal 

of the project is for them to return to their facilities and VISNs with the skills to 

train local providers in Battlefield Acupuncture, which has been used successfully 

in DOD front-line clinics around the world. This initiative ultimately aims to provide all Veterans with access to this intervention, and a wider array of pain management choices generally, when they present with chronic pain. 

INTEGRATIVE HEALTH—THE WAY FORWARD

In late 2012, the Under Secretary for Health appointed a Team to review the organizational structure to support implementation of integrative health strategies in 

VHA. The Team recommended the expansion of the VHA Office of Patient Centered 

Care and Cultural Transformation’s (OPCC&CT) capacity to develop and implement 

integrative health strategies in clinical activities, education, and research. 

OPCC&CT is now serving as the lead office in this work, expanding on existing efforts and with active partnerships across the organization. An Acting Director of 

VHA’s Integrative Health Coordinating Center (IHCC) has been named and recruitment for core staff is in process. Additional staffing is being vetted now and that 

will continue until the program is fully developed. 

OPCC&CT has deployed a number of clinical, research, and education strategies 

to begin developing a more coordinated approach. This includes clinical pilots, work 

within the existing Centers of Innovations, and close alignment with the Office of 

Research and Development, as well as creating curricula and expanding education 

in these areas. VA’s Evidence Synthesis program, in conjunction with OPCC&CT 

and Patient Care Services, is examining the scientific literature on various CAM 

modalities and presenting the findings in the form of an evidence map. At the 

present time, reviews are being done on Yoga, Tai Chi, and mindfulness meditation 

and a review was recently completed on acupuncture. The evidence map on acupuncture showed a positive effect of acupuncture on headaches, migraines, and 

chronic pain as well as a potential positive effect in multiple domains including depression and insomnia. The information from these reviews will help guide decision 

on how to best use CAM modalities within VA. 

The Whole Health Clinical Education Program, which includes an integrative 

health focus, launched last year, has received outstanding evaluation feedback from 

the clinicians and leadership who have taken the course. An online curriculum is 

under development and will have greater than 40 modules. These have been co-created with VA and the University of Wisconsin, leaders in the field of Integrative 

Medicine. 

18 

11Lippe P.M., Brock C., David J.J., Crossno R., Gitlow S. The First National Pain Medicine 

Summit—Final Summary Report. Pain Med 2010;11(10):1447–68. 

Finally, the DOD/VA Health Executive Council (HEC) Pain Management Work 

Group (PMWG) was chartered to develop a model system of integrated, timely, continuous, and expert pain management for Servicemembers and Veterans. The Work 

Group participates in VA/DOD Joint Strategic Planning (JSP) process to develop 

and implement the strategies and performance measures, as outlined in the JSP 

guidance, and shares responsibility in fostering increased communication regarding 

functional area between Departments. The Group also identifies and assesses further opportunities for the coordination and sharing of health related services and 

resource between the Departments. A key development is the HEC PMWG’s sponsoring of two Joint Incentive Fund projects to improve Veterans’ and Servicemembers’ access to competent pain care in the SCM-PM: the Joint Pain and Education Project (JPEP), and the ‘‘Tiered Acupuncture Training Across Clinical Settings’’ (ATACS) projects. 

OVERSIGHT AND ACCOUNTABILITY

Several key responsibilities are articulated in the Pain Management Directive. 

The Directive establishes a National Pain Management Program Office (NPMPO) in 

VACO that has the responsibility for policy development, coordination, oversight, 

and monitoring of VHA’s National Pain Strategy. The Directive further authorizes 

the establishment of a multidisciplinary VHA National Pain Management Strategy 

Coordinating Committee that supports the Program Office in achieving its strategic 

goals and objectives. The Committee is comprised of 15 members to include: anesthesiology, employee education, geriatrics and extended care, mental health, neurology, nursing, pain management, patient education, pharmacy benefits management, primary care/internal medicine, quality performance, rehabilitation medicine, 

research, and women Veterans’ health. 

The Directive requires VISN Directors to ensure that all facilities establish and 

implement current pain management policies consistent with this Directive. The 

NPMPO maintains records of VISN and facility compliance, along with other key 

organizational requirements contained in the Directive. All VISNs and facilities 

have appointed National Pain Office pain management points of contact, established 

multidisciplinary committees, and implemented pain management policies as required by the Directive. Health Care Provider Education and Training 

First, as recognized by the IOM in its extensive 2011 review, ‘‘Pain in America’’ 

and the American Medical Association in its 2010 Report on Pain Medicine 11, and 

as articulated in VHA’s Pain Management Directive in 2009–053, a formal commitment to pain management education and training for all appropriate clinical staff 

is required. 

The Joint Pain and Education Project, JPEP, mentioned earlier, has proposed 

training faculty in all VA training sites to pursue the implementation of such a curriculum; new generations of providers and other clinicians will themselves ultimately become the practitioners and teachers of good pain care. JPEP will target 

all levels of learner: the Veteran and his/her family and caregiver; the public; clinicians from all disciplines; specific providers and clinicians in practicing at each level 

of the SCM-PM: primary care, pain medicine specialty care, and other specialty 

care. VA is providing national leadership in developing interdisciplinary and discipline-specific competencies for pain management, in developing a system-wide approach to trainings, and in providing leadership roles in national projects to improve 

pain education and training. 

CONCLUSION

Mr. Chairman, I would be the last person to say that we are now right where 

we want to be with our pain care in VA, but I will be the first person to say that 

we are well along in the process of getting there. I am confident that we will be 

setting standards for pain care nationally in the coming years. We are confident 

that we are building more accessible, safe and effective pain care that will be responsive to the needs of our Veterans and will better serve to enhance the quality 

of their lives. VA is committed to providing the high quality of care that our Veterans have earned and deserve, and we appreciate the opportunity to appear before 

you today. My colleagues and I are prepared to respond to any questions you may 

have. 

19 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. BERNARD SANDERS TO

ROBERT A. PETZEL, MD, UNDER SECRETARY FOR HEALTH, VETERANS HEALTH ADMINISTRATION (VHA), U.S. DEPARTMENT OF VETERANS AFFAIRS

OPIOID SAFETY INITIATIVE

Question 1. How does VA plan to implement the Opioid Safety Initiative systemwide? 

Response. The Veterans Health Administration (VHA) has been vigorously pursuing implementation the Opioid Safety Initiative (OSI) to ensure optimal pain 

management and to safeguard Veterans from harm inherent in high-risk medications such as opioids and benzodiazepines. The objective of OSI is to make the totality of opioid use visible at all levels in the organization with a particular emphasis 

on identifying and remediating prescribing practices that place Veterans at increased risk for adverse outcomes. To this end, VHA has embarked on a systemwide program of education and training in pain management, opioid safety, access 

to alternative medical and non-medical treatments for pain, and patient education 

in self-management. These programs are manifestations of the core principles and 

policies outlined in the 2009 Directive and are emphasized in the new draft Directive which is in development. In the meantime, Directive 2009–053 remains as VHA 

policy until replaced with the new Directive. To assist Veterans, providers and clinical teams in achieving OSI goals for safer opioid prescribing practices, an interdisciplinary VHA Task Force assembled a 15 module, peer-reviewed OSI Toolkit 

that is continually updated as new information becomes available, including new 

evidence-based practices. The OSI Toolkit is accessible to all VHA clinicians and disseminated widely and repeatedly through multiple communication channels and 

educational formats to facilitate safe opioid prescribing practices. 

a. What is the timeline for full implementation? 

Response. While The Opioid Safety Initiative (OSI) was launched in October 2013, 

it is an on-going endeavor, comprised of multiple inter-disciplinary approaches, 

which will be constantly evaluated, modified and/or introduced to effective pain 

management and decrease the risks for complications due to both over- and undertreatment with opioids and other therapies. As an example, VHA OSI Task Force 

assembled a 15 module, peer-reviewed OSI Toolkit that is continually updated as 

new information becomes available, including new evidence-based practices. 

Question 2. What are the implications of the Opioid Safety Initiative beyond pain 

care, such as reducing the reliance of medications to treat mental health conditions? 

Response. VHA original response: The Opioid Safety Initiative addresses the risks 

of opioid analgesia comprehensively through a system-wide program with the following aims that include management of Veterans with co-morbid pain and mental 

health conditions: 

• To reduce risks, such as high opioid doses, co-prescribing of benzodiazepines, 

close monitoring of Veterans with urine drug screens and Veterans with risks such 

as substance use disorders (addiction) and PTSD. 

• To encourage the use of psychological, physical and complementary and alternative medicine (CAM) therapies such as acupuncture and yoga in pain management. 

• To provide feedback and educational support for our clinical teams caring for 

patients with co-morbid pain and mental health disorders. 

Question 3. How does VA plan to publicize this initiative—particularly to veterans 

who may have avoided seeking treatment in the past because of concerns regarding 

medication? 

Response. VHA has embarked on a system-wide program of education and training in pain management, opioid safety, access to alternative medical and non-medical treatments for pain, and patient education in self-management. These programs 

are manifestations of the core principles and policies outlined in the 2009 Directive 

and are emphasized in the new draft Directive which is currently in concurrence. 

In the meantime, Directive 2009–053 remains VHA policy until replaced with the 

new Directive. 

Question 4. One of the goals of the Opioid Safety Initiative is to facilitate use of 

state prescription databases. In which state prescription databases is VA able to 

participate? Is VA currently participating in all of the databases where it is able? 

Response. As of the date of this response, Prescription Drug Monitoring Program 

(PDMP) deployment is completed in 29 states, and is scheduled for completion in 

6 more states by the end of August 2015. Please note that in 2 of these 6 states— 

Florida and Oregon—PDMP deployment is very near completion. In Florida, 4 of 6 

sites are transmitting and in Oregon, 2 of 3 sites are transmitting. Deployment will 

20 

occur in 13 other states by December 2016. The longer implementation period for 

these 13 states is due to their individually customized PDMP requirements that VA 

is working to satisfy. One state—New Mexico—has advised the Department that it 

needs to purchase and install new software to support a PDMP, and that its 

timeline to accomplish this purchase is not yet determined. This issue affects all dispensing pharmacies within New Mexico. VA stands ready to activate the transmission of prescription drug data to New Mexico’s PDMP system as soon as the 

state is ready. Missouri is the only state that has not enacted a PDMP law. The 

District of Columbia is currently developing its recently enacted PDMP. A complementary effort to PDMP deployment is the issuance of the VHA Directive, 

Querying State Prescription Drug Monitoring Programs, which we are planning to 

publish in the coming months. This Directive would establish policy requiring VHA 

health care provider participation in state PDMPs, consistent with applicable state 

laws. The Directive would assign responsibility to each facility Director to ensure 

that local policy and processes are established to support the Directive. Specifically, 

the Directive would outline when a query is needed, the frequency of a query, and 

any exclusions. Specifically, the draft would exclude any controlled substance prescription that is a 5 day supply or less without refills and any patient who is enrolled in Hospice care, unless required by state law. 

COMPLEMENTARY AND ALTERNATIVE MEDICINE (CAM)

Question 5. VA offers a number of CAM therapies, but they are not necessarily 

evenly distributed across the system and veterans are not always aware of what’s 

available to them. What is VA doing to more evenly distribute access across the system? What is VA doing to inform veterans their options for CAM therapies? What 

is VA doing to encourage providers to offer these therapies and how is this being 

tracked? 

Response. VA is committed to offering Veterans more personalized, proactive and 

patient driven care. This entails better understanding of the needs and desires of 

Veterans and addressing their health care goals in a more holistic fashion. VHA has 

established an Integrative Health Coordinating Center whose mission is to help 

evaluate and where appropriate help integrate Complementary and Integrative 

Health (CIH) services into VA. In addition, the Office of Patient Centered Care and 

Cultural Transformation (OPCC&CT) has developed education on Whole Health, 

which is being disseminated throughout VA. These courses educate providers on 

how to approach healthcare in a more holistic fashion and educates them on CIH 

practices and how these may be able to play a part in Veterans healthcare. This 

education on CIH practices will expand the resources available to providers when 

they engage their patients in identifying their healthcare goals and the strategies 

they wish to embark on to attain these goals. As VA offers personalized, proactive, 

patient-driven care it is through educating providers that we work to ensure that 

Veterans have a discussion with their provider and discuss the best treatment option including all appropriate therapies including indicated CAM/CIH which is 

unique to the Veteran and their circumstance. VHA’s educational programs for clinical staff are being disseminated in the field. These clinical courses educate providers on how to approach health care in a more holistic way and educates them 

on CAM therapies available. Other efforts are underway to provide information to 

Veterans. One example is that OPCC&CT developed an internet site as the focal 

point for messaging, resource delivery, and community engagement for the patient 

centered care body of work and the Veteran-facing products developed to educate 

and communicate with Veterans. Through the Health for Life site, we are providing 

products that enable Veterans to achieve their greatest health and well-being. 

OPCC&CT has also trained field implementation teams that are being deployed 

around the country to work with local leadership to create a culture that supports 

a whole health, patient-centered model inclusive of CIH services. They have developed an education campaign that includes both internal and external customer facing modules describing the new models of care and services that focus on putting 

the patient at the center of their care to create a personalized, proactive, patientdriven model. 

Question 6. What factors limit VA from further broadening CAM therapies across 

the VA Health Care System? 

Response. The medical benefits package states that VA may offer those services 

that are in accord with generally accepted standards of medical practice. There are 

a vast number of Complementary and Integrative Health (CIH) practices, but the 

evidence base for many of them is limited. Questions remain about the efficacy of 

many of these practices, who responds to them, how they should be used, and for 

how long. Although no CIH practice is the gold standard for care, several practices 

21 

show promise as adjuncts to care. In addition, many CIH practices lack standardized education, training, certification and licensure standards. These factors, combined with a lack of occupational classes for CIH practitioners within VA, pose significant barriers to the hiring of such providers within VA. 

DOD/VA COLLABORATION

Question 7. What benefits has VA seen from the standardization of the prescription medication between VA and DOD available to both servicemembers and veterans? Are servicemembers able to continue their existing course of treatment as 

they transition to VA health care? 

Response. Yes, Servicemembers are able to continue their existing course of treatment as they transition to VA health care, unless a change would be warranted 

based on a VA provider’s clinical assessment (i.e., drug is no longer effective, patient’s changing medical condition warrants a change, drug is no longer safe given 

clinical circumstances, etc.). There have been widespread anecdotal reports of Servicemembers’ mental health and pain medications being switched due to differences 

between the VA and DOD drug formularies. However, these anecdotes were not substantiated in a medication continuity pilot evaluation of over 2,000 Servicemembers 

recently conducted by VA. In this pilot evaluation, VA found that 99% of patients 

receiving a mental health or pain medication were able to continue those medications despite differences between the VA and DOD formularies. The data from VA’s 

pilot evaluation validates VA’s long standing practice of continuing medication therapy started by Department of Defense prescribers. See (http://www.pbm.va.gov/ 

PBM/vacenterformedicationsafety/othervasafetyprojects/DOD—VA—Medication— 

Continuation—Report.pdf). 

Question 8. What other efforts have DOD and VA taken to collaborate and standardize treatment options for servicemembers and veterans for the treatment of 

chronic pain and mental health conditions? 

Response. The DOD/VA Health Executive Council’s Pain Management Work 

Group ( HEC PMWG), which meets monthly, was chartered in 2010 to ‘‘actively collaborate in supporting the development of a model system of integrated, timely, continuous, and expert pain management for Servicemembers and Veterans.’’ The HEC 

PMWG has articulated 6 objectives for its present work: 

Objective 1—Standardize Pain Measurement. The PMWG has sponsored the development of the Defense and Veterans Pain Rating Scale to improve the measurement of pain. The tool has been validated and published, is in use in multiple military facilities and in civilian hospitals. Additional validation studies continue in 

DOD and VHA. 

Objective 2—Develop a clinical pain support tool and pain data registry. The PASTOR tool, incorporating the NIH ‘‘PROMIS’’ patient report outcome measures and 

computer adaptive testing, is under development and is being piloted in a collaboration between Madigan Army Hospital, NIH, and the University of Washington. 

Objective 3—Standardize Suboxone (buprenorphine and naloxone) Prescribing 

Practices. A common guidance document is developed and VHA and DOD working 

implementation in each organization. 

Objective 4—Develop Medical Drug Testing guidance. The PMWG developed DOD/ 

VHA core guidance and have developed and share clinical education and training 

in JPEP modules and in the Opioid Safety Initiative Toolkit. 

Objective 5—Develop Acupuncture Credentialing guidance. The PMWG developed 

shared DOD/VHA core guidance for VHA and DOD clinicians and is working implementation of core guidance within their respective organizations 

Objective 6—Develop Informed Consent for Long-term Opioid Therapy. The VHA 

developed and approved a patient education document, ‘‘Taking Opioids Responsibly,’’ to assist in the informed consent process, and the DOD is evaluating the 

VHA document for implementation in DOD. 

Currently there are two Joint Investment Fund (JIF) supported projects to improve the competencies of our workforce across both systems: 

• The Joint Pain Education and Training Project (JPEP). 

– Has developed 35 optional evidence-based training modules in pain management for use in its multiple pain education programs to help standardize pain 

management education and training across the two health systems and to support and educate clinicians and Veterans about safe and effective stepped pain 

management, including use of opioids. 

– JPEP modules are being used for primary care residency training and for 

practicing clinicians and clinical teams being trained by the Pain Mini-resiVerDate Mar 15 2010 19:16 Jul 24, 2015 Jkt 000000 PO 00000 Frm 00025 Fmt 6633 Sfmt 6621 Z:\ACTIVE\043014.TXT PAULIN
22 

dency, Pain SCAN ECHO, asynchronous web-based courses, and Community of 

Practice conferences. 

– All these programs reach across the VHA to train primary care providers in 

all settings in the assessment and treatment of pain and in the use of patient 

education in self-management, the use of multiple modalities such as behavioral, integrative medicine, and physical therapies and the use of consultant 

specialists in pain, mental health, and CAM. 

– On the topic of opioids safety, for example, these programs have presentations on universal precautions and risk management, including clinical evaluation, written informed consent, screening such as urine drug monitoring, use 

of state prescription monitoring programs, and safe tapering. 

• The Tiered Acupuncture Training Across Clinical Settings (ATACS) 

– Has trained more than 1290 front-line providers in the VA and DOD in Battlefield Acupuncture as well as dozens of physicians in medical acupuncture. 

– Represents VHA’s initiative to make evidence-based complementary and alternative medical therapies widely available to our Veterans throughout VHA. 

– Provides Veterans with a wider array of pain management choices when they 

present with chronic pain. 

ACUPUNCTURE TRAINING

Question 9. How would the Joint Incentive Fund Project to implement a standardized acupuncture training and sustainment model across DOD and VA medical facilities improve acupuncture services VA provides veterans? When can we expect 

system-wide implementation of this joint model? 

Response. By providing standardized training in the short course for Battlefield 

(auricular) Acupuncture (BFA) to hundreds of providers across the system, and by 

credentialing trainees to add BA to their pain management toolbox, these providers 

will be able to use this treatment as one of many they have to offer Veterans with 

pain. The physicians being trained in Medical Acupuncture will also be trained as 

BFA Faculty, so they can train their local facility providers in BFA to sustain the 

program’s development system-wide. 

Question 10. How many providers are trained in acupuncture already working in 

the VA Health Care System? How many of these providers are exclusively providing 

acupuncture? What is the average number of hours each provider trained in acupuncture offers this therapy each week? 

Response. We do not have information on the number of providers based at facilities who provide acupuncture or how many hours a week therapy is provided. However, from the 2015 Healthcare analysis and information group survey on VA Complementary and Integrative Health practices, we do know that 79 facilities offer acupuncture services primarily performed by physician-trained acupuncturists as a part 

of their duties at least a half day per week up to several times a week. 

Question 11. What efforts are being made to ensure an adequate number are 

available to treat veterans once the joint model is implemented? 

Response. At the current time, physicians and chiropractors are the only VHA occupations with scopes of practice that include acupuncture. As a result, the availability of trained acupuncture providers within VA is limited. VA continues to support the training of physicians in acupuncture, but is also pursuing the development 

of a licensed acupuncturist occupational class within VHA. The addition of licensed 

acupuncturists to VHA occupations will expand VHA’s ability to hire trained acupuncture providers. 

PAIN MANAGEMENT DIRECTIVE

Question 12. On October 28, 2009, VA issued the Pain Management Directive to 

improve VHA’s processes for treating and managing chronic pain. How has systemwide implementation of the National Pain Management Strategy—as required by 

the Pain Management Directive—improved VA’s approach to pain management? 

Response. The implementation of Stepped Care has increased resources for primary care pain management, such as behavioral health clinicians, access to CAM, 

access to multidisciplinary pain specialty clinics, and access to tertiary care Commission on Accreditation of Rehabilitation Facilities (CARF) rehabilitation 

programs. 

Question 13. Does VA plan to extend the Pain Management Directive? If not, 

please explain why not. If so, please explain whether it will be extended in its current form or if changes will be made. 

23 

Response. Yes, a new Directive has been drafted and is undergoing VHA Concurrence. Until which time the new Directive is approved, the current Pain Management Directive will remain in effect. 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. MARK BEGICH TO ROB- ERT A. PETZEL, MD, UNDER SECRETARY FOR HEALTH, VETERANS HEALTH ADMINIS- TRATION (VHA), U.S. DEPARTMENT OF VETERANS AFFAIRS

Question 14. My office has received casework from veterans who have severe 

PTSD issues that affect their day to day life, and say I quote ‘‘I’m pretty much done 

with medications.’’ They have asked for Hero Dogs, who raise and train service dogs 

and places them free of charge with our Nation’s Veterans to improve quality of life 

and restore independence. Veterans with disabilities have given enough. 

Tell me what the VA is doing with expanding service/therapy dogs; I think this 

would be a cheaper option and a safer option rather than treating with opioids and 

other drugs. 

Response. Veteran preference is an important consideration when choosing a 

therapeutic approach to treat PTSD. Effective cognitive behavioral therapies are 

made available to every Veteran who seeks VA care for PTSD. VA is currently attempting to find ways to increase Veteran engagement with these treatment modalities and increase the likelihood that Veterans remain in treatment until remission 

or significant clinical improvement is accomplished. While dogs and other animals 

can provide great comfort and companionship, and we do not disagree with Veterans’ subjective accounts that service dogs have improved the quality of their lives. 

At this time, there is not sufficient evidence that animals are effective in the treatment of mental health conditions, including Post Traumatic Stress Disorder (PTSD). 

Consequently, VA does not provide service dog benefits for mental health service 

dogs. VA is currently evaluating the efficacy of mental health service dogs pursuant 

to a congressionally mandated study to learn whether service dogs and/or emotional 

support dogs can be effective in treating or rehabilitating persons with PTSD. The 

study, expected to take several years to complete, is currently ongoing at three sites 

(Atlanta, GA; Iowa City, IA; and Portland, OR) and has begun pairing enrolled Veterans with dogs. 

Question 15. The following is from a veteran in Kenai: ‘‘I’m on ten different types 

of medications that deal with sleep, back pain, depression, anxiety, blood pressure, 

and inflammation * * *. I’ve really lost count of what I’m taking. I’m sick of it. I 

don’t want to take any more medications. I would like to see if we can make a push 

for the VA to fund holistic style medical treatments. I believe in these, and I believe 

that they are cheaper rather than pushing big pharma on us. I for one am sick of 

it and would rather live in a state of depression and anxiety as opposed to taking 

10+ pills a day. I’m also battling with the VA for an increase in VET benefits. They 

have turned down request for shoulder pain connected disability; they’ve turned 

down requests for increase in ringing in my ears but will give me pills!’’ 

I am glad the VA and the Committee is addressing this, it is very real, and how 

would you respond to this veteran? 

Response. Thank you for raising this important point. The problems you mention 

affect our entire nation and this is an issue we are challenged to manage effectively 

for our Veterans as well. The VA is actively addressing these problems in multiple 

ways, as well as contributing to the national effort, outlined in the National Pain 

Strategy, to improve the education and training of all health professionals, including 

those who eventually will care for our Veterans and military. The potential for side 

effects and toxicity increases when medications that affect the central nervous system (the brain and spinal cord) are prescribed together for symptoms of different, 

but sometimes related, conditions such as sleep disorders, chronic pain conditions, 

anxiety and depression disorders, Traumatic Brain Injury (TBI) and PTSD. To help 

combat this problem the VA can take advantage of its unique combination of assets, 

such as its electronic medical record and its Veterans Health Administration (VHA)- 

wide communication and education systems which reach all facilities and providers. 

VHA has developed a new tool, the Opioid Therapy Risk Report (OTTR), which 

is available now to all VHA Primary Care clinicians when treating a Veteran with 

opioid therapy for chronic pain. This report provides information about the dosages 

of opioid analgesics and other centrally active medications such as benzodiazepines, 

significant medical and psychiatric problems that could contribute to an adverse 

drug reaction, and monitoring data to aid in the review and management of complex 

patients. OTTR is right on the dashboard of the electronic medical record, which enables VA providers to review this pertinent clinical data related to pain treatment 

all in one place while actually talking to patients about their symptoms and medicaVerDate Mar 15 2010 19:16 Jul 24, 2015 Jkt 000000 PO 00000 Frm 00027 Fmt 6633 Sfmt 6621 Z:\ACTIVE\043014.TXT PAULIN
24 

tions. As a result, Veterans are afforded a comprehensive Veteran-centered and 

more efficient level of pain management not previously available to Primary Care 

providers. VHA is actively deploying training aids to providers and facilities to familiarize them with how to utilize this tool in their daily practice. 

VHA has formalized several education and academic detailing projects that provide all VA prescribers and facilities guidance and education on safe symptom management. One program is the OSI, which monitors reductions in potential risks such 

as prescribing opioids and benzodiazepines together or high doses of opioids, monitors how facilities are increasing the use of evidence-based alternative treatments 

such as cognitive behavioral therapies and integrative medicine (CAM) (which are 

now required to be available in all facilities as alternatives to medication), and also 

provides feedback and support for providers whose prescribing profiles do not meet 

acceptable clinical standards. An OSI Toolkit with detailed education and guidance 

for both providers and patients is available on the VA’s Pain Management Intranet 

and Internet sites and has been widely presented throughout the VHA in multiple 

educational formats and communications. For example, the Toolkit has detailed instructions about guiding safe medication tapers when clinically indicated. 

Programs such as the ATACS are presently training physicians in medical acupuncture and providers in ‘‘battlefield (auricular) acupuncture’’ across both systems. 

Already 1,293 Providers have been trained in battlefield acupuncture in military 

treatment facilities VA hospitals across the country. 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. RICHARD BLUMENTHAL

TO ROBERT A. PETZEL, MD, UNDER SECRETARY FOR HEALTH, VETERANS HEALTH

ADMINISTRATION (VHA), U.S. DEPARTMENT OF VETERANS AFFAIRS

Question 16. I have heard from one of my constituents that it is difficult for some 

veterans to obtain their VA Identification Card, which is required to obtain VA 

health benefits. Can you please provide information about the process a veteran 

needs to follow and what are the criteria to obtain these benefits? 

Response. The Veterans Health Identification Card (VHIC) is for identification 

and check-in at VA appointments. It cannot be used as a credit card or an insurance 

card, and it does not authorize or pay for care at non-VA facilities. To receive a 

VHIC, a Veteran must be enrolled. If the Veteran is not enrolled, the Veteran may 

apply for enrollment online at www.va.gov/healthbenefits/enroll, by calling 1–877– 

222–VETS (8387), or apply for enrollment in person at his or her local VA medical 

facility. 

In February 2014, VA began issuing the VHIC to newly enrolled Veterans and enrolled Veterans who were not previously issued the old VIC but requested an identification card. Enrolled Veterans who were not issued the old VIC may contact their 

local VA medical center Enrollment Coordinator to arrange to have their picture 

taken for the new VHIC, or they may request a new VHIC at their next VA health 

care appointment. 

Veterans who are already enrolled should ensure the address VA has on file is 

correct so you can receive your VHIC in a timely manner. For more information, 

please visit http://www.va.gov/HEALTHBENEFITS/vhic/index.asp. 

Chairman SANDERS. Dr. Petzel, thank you very much. 

General Coots. 

STATEMENT OF BRIGADIER GENERAL NORVELL V. COOTS, 

USA, DEPUTY COMMANDING GENERAL (SUPPORT), U.S. 

ARMY MEDICAL COMMAND AND ASSISTANT SURGEON GENERAL FOR FORCE PROJECTION, OFFICE OF THE SURGEON 

GENERAL, U.S. ARMY; ACCOMPANIED BY COLONEL KEVIN T. 

GALLOWAY, USA, DIRECTOR, ARMY PAIN MANAGEMENT 

PROGRAM, REHABILITATION AND REINTEGRATION DIVISION 

General COOTS. Chairman Sanders, Ranking Member Burr, and 

distinguished Members of this Committee, thank you for the opportunity to appear before you to discuss some of the Army Medicine’s 

initiatives to address health and pain management needs of our 

25 

servicemembers. I am accompanied by Colonel Galloway, who is 

the director for Army Medicine’s Pain Management Program. 

On behalf of the over 150,000 dedicated soldiers and civilians 

that make up Army medicine, I want to extend our appreciation to 

Congress for the support given to military medicine which provides 

the resources we need to deliver leading-edge health services to our 

warriors, families, and retirees. 

The Army has been engaged over the last 13 years in combat operations and related activities that have challenged the bodies and 

spirits of our soldiers and their families. Army medicine has 

worked with our sister services and the Veterans’ Health Administration to meet the emerging medical needs of our servicemembers 

and veterans. 

Our initiatives which are detailed further in my written testimony are aimed at improving outcomes, increasing safety, and enhancing the transition of care to the VA. 

Treating pain is one of medicines oldest and more fundamental 

responsibilities. Yet modern medicine continues to struggle in its 

efforts to understand pain mechanisms and to relieve pain and suffering of our patients. These complex issues impact patients, providers, leaders, and organizations across the military, the VA, and 

in the civilian sector. Effective solutions must involve innovative 

strategies, comprehensive solutions, and collaborative efforts. 

While the complicated nature of pain management and overmedication is not unique to the military or military medicine, we do face 

some unique challenges. We provide medical care on the battlefield 

and across an 8,000-mile medical evacuation chain that moves injured servicemembers from remote locations to U.S. hospitals with 

lightening efficiency. 

I have been there receiving our wounded warriors during my 

time in Afghanistan as well as at Walter Reed when I was the hospital commander. I know that for military medical providers, we 

begin pain management on the battlefield at the point of injury 

and continue throughout evacuation, treatment, and recovery. 

Army medicine initiative aimed at non-opioid medications and 

regional nerve blocks to provide local relief are important to expanding opioid sparing strategies at the earliest moments of care. 

In 2010, the Army-led pain management task force was chartered to develop a comprehensive, holistic, and multi-disciplinary 

pain management strategy for the DOD. The Army has been working to implement the task force recommendations through the 

Army pain management campaign and while continuing to build 

collaborations both inside and outside of the Department of 

Defense. 

Current Army initiatives are aimed at improving pain management, patient care and safety, and reducing adverse outcomes related to prescription drugs. These are all a part of comprehensive 

strategy that includes establishing a network of standardized pain 

management capabilities, developing the DOD pain assessment 

screening tool, and outcomes registry by leveraging previous NIH 

investment in research, comprehensive medication reviews, and 

pharmacy screening tools within the medical home which is our 

primary care model to identify active duty servicemembers at increased risk, expanding the role of clinical pharmacists by embedVerDate Mar 15 2010 19:16 Jul 24, 2015 Jkt 000000 PO 00000 Frm 00029 Fmt 6633 Sfmt 6601 Z:\ACTIVE\043014.TXT PAULIN
26 

ding them in the medical home as a member of the comprehensive 

care team, improving pain management specialty support to primary care providers through-out pain ECHO tele-mentoring initiative, expanding our understanding and utilization of effective integrative medicine modalities such as acupuncture, yoga, medical 

massage, and biofeedback through our collaborative partnerships 

and collaboration with the National Center for Complementary and 

Alternative Medicine and the Defense and Veterans’ Center for Integrative Pain Management on research studies of non-medication 

complements or alternatives to standard pain management 

therapies. 

There efforts have been associated with fewer adverse drug-related events, reduced hospital admissions, improved patient outcomes, and overall cost avoidance. 

Finally, I would like to mention ongoing work with the VA to endure the smooth transition of care as servicemembers enter the VA 

system. The overarching pain management task force objective is 

to provide a standardized DOD and VA approach to optimize the 

care for warriors and their families. 

Our providers and patients benefit from a standardized approach 

to pain management while they are in uniform and as they transition to the VA health care system. 

I want to thank my partners in the DOD, the VA, and our colleagues testifying here today for the efforts made and our shared 

goals. 

I also want to thank Congress and the Committee for your continued support and I look forward to your questions. Army medicine is serving to heal and honored to serve. 

[The prepared statement of General Coots follows:] 

PREPARED STATEMENT OF BRIGADIER GENERAL NORVELL V. COOTS, DEPUTY COMMANDING GENERAL (SUPPORT), U.S. ARMY MEDICAL COMMAND AND ASSISTANT

SURGEON GENERAL FOR FORCE PROJECTION, OFFICE OF THE SURGEON GENERAL, 

UNITED STATES ARMY AND COLONEL KEVIN T. GALLOWAY, ARMY PAIN MANAGEMENT PROGRAM DIRECTOR, REHABILITATION AND REINTEGRATION DIVISION, OFFICE

OF THE SURGEON GENERAL, UNITED STATES ARMY

Chairman Sanders, Ranking Member Burr, and Distinguished Members of this 

Committee—thank you for the opportunity to appear before you to discuss some of 

the Army Medicine’s initiatives to address healthcare needs of our Soldiers, specifically as they relate to the challenges the entire Nation is facing with pain management and the use of opioids. On behalf of the over 150,000 dedicated Soldiers and 

civilians that make up Army Medicine, I want to extend our appreciation to Congress for the support given to military medicine, which provides the resources we 

need to deliver leading edge health services to our Warriors, Families and Retirees. 

I’m accompanied today by Colonel Kevin Galloway, Director for Army Medicine’s 

Pain Management Program. 

The Army has been engaged over the last 13 years in combat operations and related activities that have challenged the bodies and spirits of our Soldiers and their 

families. Throughout this intensive period of military operations, Army Medicine, 

along with our Sister Services and the Veterans Health Administration (VHA), have 

been evolving and adapting to meet the emerging medical needs of our wounded, 

ill, and injured Servicemembers and Veterans. While some of the medical challenges 

facing Servicemembers and Veterans are unique to the military and military medicine, the challenges related to pain management and the potential overuse, abuse, 

and diversion of pain medications are shared by the Nation at large. These complex 

issues impact patients, providers, leaders and organizations across the military 

health system, the VHA, and civilian medicine. Consequently, effective solutions 

and strategies will involve patients, providers, leaders and organizations across military, VHA and civilian medicine. I would like to share some of our innovative strateVerDate Mar 15 2010 19:16 Jul 24, 2015 Jkt 000000 PO 00000 Frm 00030 Fmt 6633 Sfmt 6621 Z:\ACTIVE\043014.TXT PAULIN
27 

gies, comprehensive solutions, and collaborative efforts with you today as well as 

emphasize our commitment to continuous improvement and research efforts. 

PAIN MANAGEMENT

First, I’d like to place the challenges of pain management in some context. Treating pain is one of medicine’s oldest and most fundamental responsibilities, yet modern medicine continues to struggle in its efforts to understand pain mechanisms and 

to relieve pain and suffering for our patients. Pain is an enigmatic issue for medicine that places significant burdens on patients, families, medical providers, and 

employers. Pain is the most frequent reason patients seek medical care in the 

United States. A 2011 Institute of Medicine (IOM) Report noted that more than 116 

million Americans suffer from chronic pain. The annual cost of chronic pain in the 

U.S. is estimated at $560 billion, including health care expenses, lost income, and 

lost productivity. The Centers for Disease Control identified prescription medication 

abuse as an ‘‘epidemic’’ in the United States. The military is not immune to these 

challenges. 

In 2010, the Army-led Pain Management Task Force was chartered to develop a 

comprehensive, holistic, multidisciplinary, and multimodal strategy utilizing stateof-the-art/science practices in the field. Comprised of representatives from the Uniformed Services and VHA, the Pain Management Task Force examined staff education, clinical practice, and the structure of pain management in military medicine, 

the VHA, and in civilian medicine. I would like to emphasize that the Task Force 

benefited immensely during this analysis from the VHA’s previous and ongoing initiatives to develop and implement pain management strategies. 

The 2010 Pain Management Task Force Report has been widely circulated and 

recognized across U.S. Medicine and abroad. The American Academy of Pain Medicine recognized the Pain Management Task Force with its Presidential Commendation. One year after the release of the report, the IOM released its own report entitled, ‘‘Relieving Pain in America,’’ which acknowledged and referenced the work of 

the Pain Management Task Force. More importantly, the IOM report’s findings and 

recommendations largely paralleled those contained in the Pain Management Task 

Force Report. When the IOM report was released in June 2011, the Army was already operationalizing the Pain Management Task Force’s recommendations 

through the Comprehensive Pain Management Campaign Plan. Since the release of 

the IOM report, the Army has been representing the Department of Defense on the 

National Institutes of Health (NIH) Interagency Pain Research Coordinating Committee, the Federal advisory committee created by the Department of Health and 

Human Services to enhance pain research efforts and promote collaboration across 

the government. 

The Comprehensive Pain Management Campaign Plan provides a roadmap for 

this holistic, multimodal, multidisciplinary pain management strategy. Army Medicine’s pain strategy includes several lines of effort: first, to implement a culture of 

pain awareness, education, and proactive intervention; second, to provide tools and 

infrastructure that support and encourage practice and research advancements in 

pain management; and last, to build a full spectrum of best practices for the continuum of acute and chronic pain, based on a foundation of the best available medical evidence. 

The foundation of the MEDCOM pain management program is developing a tiered 

or ‘‘Stepped Care’’ strategy that provides the appropriate level of pain management 

capability, provider education and access to consultative/referral support at each 

level of care (i.e. from Primary Care to Specialty Care). Interdisciplinary Pain Management Centers (IPMC) are being established at each of the Army’s eight medical 

centers. IPMCs provide the highest tier of pain management delivered by a multidisciplinary team of providers working together to provide consultation, care, and 

expertise for interventional pain medicine. Our goals are rehabilitation and functional restoration through these integrative medicine modalities. 

The Army Pain Management Extension for Community Healthcare Outcomes 

(ECHO) tele-mentoring initiative leverages the model developed by the University 

of New Mexico (UNM) Project ECHO initiative. The Army is completing a two-year 

collaboration with UNM to adapt this best practice for use in the Army’s pain program. ECHO’s objective is to complement the capacity, competence and confidence 

of remote primary care providers. Utilizing weekly video teleconferencing to create 

regional communities of practice, ECHO links the IPMC specialty teams (i.e. hubs) 

with their designated Patient Centered Medical Homes (i.e. spokes). This improves 

provider knowledge, increases care coordination, and decreases the need for continued specialty referrals to the direct and purchased care systems. 

28 

COMPLEMENTARY INTEGRATIVE MEDICINE MODALITIES

As recommended by the Pain Management Task Force, the integrative medicine 

modalities in our IPMCs include acupuncture, movement therapy/yoga, medical 

massage, and bio-feedback. The use of these modalities in our IPMCs provides our 

patients with non-medication pain management options. The Army has been collaborating with several organizations with a common interest in expanding the utilization of complementary integrative medicine modalities. The National Center for 

Complementary and Alternative Medicine at NIH, the Bravewell Collaborative, and 

the Samueli Institute have all been extremely helpful in this effort. 

Army clinicians are participating with the Air Force, Navy, and VHA in a $5.4 

million Joint Incentive Fund Project to field a standardized basic acupuncture training and sustainment model across DOD and VHA medical facilities. Training teams 

have already started traveling to Army, Navy, Air Force, and VHA medical facilities 

to deliver this training. The response from providers and patients has been overwhelmingly positive. 

Army Medicine, along with the Navy and Air Force, is collaborating through the 

Defense and Vet Center for Integrative Pain Management on research studies related to the use of acupuncture and yoga as non-medication complements/alternatives to standard pain management therapies. Initial evidence indicates these can 

be effective complements and sometimes an alternative to medications. 

PAIN OUTCOMES MEASUREMENT

In response to the 2010 National Defense Authorization Act and the recommendations in the Pain Management Task Force Report, the DOD began development of 

the Pain Assessment Screening Tool and Outcomes Registry (PASTOR). PASTOR 

was designed as a tool to reduce the burden of questionnaires during clinical contact 

through modern information technology, make use of well-established pain assessment tools already available, and provide a framework for development of new assessment tools. Furthermore, PASTOR is envisioned as a critical first step in realizing the vision of outcomes driven pain care across the DOD and VHA health care 

systems. 

The PASTOR prototype results in a clinician report, displaying alerts for concerning responses to questions covering PTSD, depression, anxiety, and alcohol use. 

These alerts are intended to prompt further individualized evaluation by the clinician. Areas of greatest pain are mapped on an image of a body, and self-reported 

pain values are tracked over time. When these scores are analyzed in concert with 

validated measures of emotional (anxiety, depression, anger) and physical (sleep, 

physical function) health domains, trends are easily identified. Additionally, each 

patient has an opportunity to list and rate ability on activities that are important 

to that individual. This functional data provides practical indicators of pain management success. A new set of opioid use measures are also under development and 

will be field tested in both civilian and military setting later this year. 

A significant advantage in the PASTOR development program is its collaborative 

partnership and development strategy with the NIH Patient Reported Outcomes 

Measurement Information Systems, or PROMIS. PROMIS represents an existing 

Federal investment of approximately $100 million, over 8 years of research and development, and the product of 150 scientists at 15 primary research sites. PROMIS 

created more than 80 royalty free instruments which can be used to capture numerous components of health related quality of life including physical health, mental 

health and social health. Computerized adaptive testing (CAT)—enables computerbased delivery of measures which can obtain clinical accuracy in five items or less. 

Scientists at Northwestern University have teamed with the military to integrate 

brief PROMIS measures with the needs of military personnel and their families who 

require pain management. This reduction in patient burden, without loss of clinical 

reliability, enables PASTOR to frequently assess multiple facets of pain and opioid 

use. 

Thus far, a working prototype has been constructed, pain threshold values for appropriate initiation of PASTOR have been identified, and a pilot test of the system 

has begun in two military treatment facilities, with more to follow in the coming 

months. 

Army Medicine is adopting the Defense and Veterans Pain Rating Scale (DVPRS). 

Something as simple as changing how we ask our patients about their pain can impact the prevalence of medication use. The scale was developed by the Pain Management Task Force and validated through DOD/VHA research studies. It recalibrates 

the pain discussion along the lines of: ‘‘How is pain affecting your function and quality of life?’’ The scale includes supplemental questions on pain’s effect on sleep, 

29 

mood, stress and activity. The Army is integrating DVPRS into the Patient Centered Medical Home workflows. 

PAIN MANAGEMENT TRANSITION TO VHA

Another area I’d like to highlight with regard to pain management is our ongoing 

collaboration with the VHA to ensure the smooth transition of care for Soldiers who 

will be receiving care in the VHA health system. Prominently positioned on the Pain 

Management Task Force Report cover is the overarching Task Force objective: ‘‘Providing a standardized DOD and VHA vision and approach to pain management to 

optimize the care for Warriors and their Families.’’ Army Medicine has continued 

to engage with the Air Force, Navy and VHA to move our organizations in that direction. The Army Pain Management Program’s incorporation of the VHA’s Stepped 

Care approach synchronizes provider education with the expectations of our patients. Not only do our military providers and patients benefit from a standardized 

approach to pain management while they are in uniform, but this also makes the 

transition to VHA care far less disruptive. 

DOD and VHA collaboration has also resulted in standardized prescription medication formularies to ensure Soldiers with chronic pain are able to continue effective 

care plans after their transition to the VHA. Last, military and VHA providers are 

engaged in a project to develop and implement a common pain management education curriculum for both providers and patients. The curriculum will be fully developed within the next twelve months, and will be implemented across VHA and 

DOD within the next eighteen months. These initiatives will take us closer to the 

standardized DOD and VHA vision and approach to pain management referenced 

by the Pain Task Force. 

In addition to the Pain Management Campaign, Army Medicine is addressing the 

potential overuse, abuse and diversion of opioids through a comprehensive strategy 

that integrates several other initiatives including Polypharmacy, Substance Abuse, 

Behavioral Health, and Warrior Transition Care. 

POLYPHARMACY

Soldiers with complex injuries often require the use of multiple medications (i.e. 

polypharmacy) which can place them at greater risk for medication-related adverse 

events. The Army seeks to reduce risk, enhance safety and optimize care by including the Soldier, Family members, healthcare providers, pharmacists and commanders as part of the healthcare team. Army policies also establish procedures to 

identify polypharmacy trends that could lead to misuse by Soldiers and Wounded 

Warriors. 

Army Medicine uses best practices that are comparable to, or exceed, civilian programs, such as prescription drug monitoring to identify polypharmacy cases. Positive interventions include comprehensive medication reviews, sole provider programs, limiting the dispensed supply of medication, restricting high-risk patients to 

the utilization of one pharmacy, informed consent, use of non-drug treatment options, clinical pharmacist referrals, and patient and provider education. 

The Army trains its providers on the risks of prescription opioid overuse and ways 

to prevent medication misuse. The US Army Public Health Command and the Uniformed Services University of the Health Sciences developed an interactive 

storyline-based training aimed at increasing the knowledge and skills health professionals need to better interact with Soldiers in a clinic setting. Army Medicine has 

implemented systems and procedures our clinicians regularly use to prevent and detect issues of opioid overuse. These tools include the ability for our clinicians to review all prescriptions paid for by the Defense Health Agency (DHA) pharmacy benefit regardless of the point of service (Military, Home Delivery or Retail Pharmacy). 

The DHA Pharmacoeconomic Branch Web site allows clinicians to identify concerning use of opioids dispensed under the TRICARE Pharmacy Benefit through the 

use of prescription screening tools such as the Medication Analysis and Reporting 

Tools. 

Army Medicine is expanding the role of clinical pharmacists to address national 

concerns with polypharmacy and adverse drug events that lead to hospital admissions. The Army Surgeon General supports evidence-based enhancements drawing 

on the expertise and contributions of pharmacists embedded in Patient-Centered 

Medical Homes. The addition of clinical pharmacists to the patient care team translates into decreased overall costs, fewer adverse drug-related events, reduced hospital admissions, and improved medication-related patient outcomes and appropriate adherence to medications. Clinical pharmacists improve readiness of the force 

through policy and practice, systematically identifying Soldiers with polypharmacy 

risk and communicating these concerns to health care providers. The Army uses an 

30 

automated polypharmacy screening tool to screen all Active Duty Servicemembers 

monthly to identify Soldiers prescribed different combinations of high risk medications. These reports are provided to the medical team for review and follow-up. Clinical pharmacists embedded in Army medical homes optimize patient adherence to 

appropriate drug therapy by conducting medication reviews, resolving medication 

problems and recommending cost effective treatment alternatives. 

Current Army initiatives aimed at reducing adverse outcomes and harm due to 

prescription drug abuses include informed consent for polypharmacy, sole provider 

program, limiting authorized use of prescriptions to six months following the prescription fill date, adjusting the panel of drugs in random urine drug testing to include prescription drugs and polypharmacy education for healthcare providers and 

patients. 

Healthcare providers must review identified risks and potential interactions with 

the Soldier, provide education on detection and management of interactions, and 

must document informed consent in the medical record. Informed consent includes 

a brief description of discussed risks and whether or not the indication for which 

the medication is being used is a Food and Drug Administration (FDA) approved 

indication or the medication is used off-label. 

The Army policy instructs healthcare providers to have a low threshold for referring patients to Behavioral Health resources and the Sole Prescriber Program. 

Healthcare providers enroll Soldiers at increased risk of adverse effects, drug interactions, or inappropriate medication use in the Sole Prescriber Program to optimize 

care. Once enrolled, only a Soldier’s designated provider or alternate provider is authorized to prescribe controlled substances for the Soldier. If necessary, the Soldier 

may be restricted to a specific pharmacy or pharmacies by activating the Prescription Lock-out Program. 

In addition to Soldiers who are identified as having intentional or unintentional 

risk for medication overdose, healthcare providers will refer Soldiers who present 

with polypharmacy-related concerns to a clinical pharmacist. The pharmacist will 

identify medication-related problems, develop a medication action plan, and provide 

medication education to the patient. Clinical pharmacists document patient encounters and consultations for medication therapy management in an electronic medical 

record template to improve communication with providers. 

Army policy limits authorized use of prescriptions to six months following the prescription fill date. In addition, Army medical providers may prescribe only the minimum quantity of controlled substances necessary to treat an acute illness or injury, 

and quantities of controlled substances used to treat acute conditions are dispensed 

as a 30-day supply. Prescribers and pharmacists inform Soldiers that, per Army policy, controlled substance prescriptions have an expiration date of six months from 

the dispensed date, and that a positive urinalysis test for the drug after six months 

from dispensing may result in a ‘‘no legitimate use’’ finding. 

Polypharmacy education and training is available to healthcare providers and 

beneficiaries to improve appropriate prescribing and use of medications, respectively. Patient-specific training is available to Warrior Transition Units (WTU) to 

improve awareness of safe medication use, proper medication disposal, and promotion for the bi-annual drug take back events. 

Army Medicine has participated in all Drug Enforcement Agency (DEA) National 

Prescription Drug Take Back Day events since their inception in 2010. Thirty-six 

Army Military Treatment Facilities participated in the Take Back Day on 25 and 

26 October 2013, with over 2,000 patients participating and 7,491 pounds of unused 

medications collected. The Army will continue to participate in bi-annual Take Back 

events in an effort to maintain attention on the importance of appropriate disposal 

of medications that are no longer needed. Army Medicine provides support through 

coordinated public affairs communications and education directed at medical staff, 

patients, Families and military leadership, to include on-site presence at every designated event. 

SUBSTANCE ABUSE PROGRAMS

The Army continues to synchronize clinical care and processes provided through 

the Army Substance Abuse Program and Army Medical Command’s primary care 

providers, pain specialists, and behavioral health specialists. The Army uses the 

DOD’s drug testing program to test not only for illegal drugs, but also for prescribed 

medications taken inappropriately (that is without an active prescription). Identified 

Soldiers are referred to the Army Substance Abuse Program where they are assessed and enrolled for treatment. Commanders and clinicians support this treatment process regardless of the Soldier’s disposition, because we recognize that we 

31 

have an obligation to ensure our Soldiers remain effective on active duty or make 

their transition from active service with drug use properly managed. 

BEHAVIORAL HEALTH PROGRAM

Army Medicine’s Behavioral Health Service Line is an interconnected group of 

standardized programs delivering a wide variety of Behavioral Health services to 

Soldiers and beneficiaries. For the treatment of substance abuse disorders, the 

Army has five Addiction Medicine Intensive Outpatient Programs. There are currently 187 beds designated for long-term Substance Use Disorder treatment in the 

Military Health System, 22 of which are in the Army. These Military Health System 

facilities have consistently had 85% or higher utilization rates for the past 18 

months. Purchased care inpatient substance use disorder treatment accounts for approximately 70 Soldiers per month. Demand for network inpatient substance use 

disorder treatment has decreased sharply with the implementation of the NDAA 

2010, Section 596, but continues to remain high enough to justify increases in capacity in the coming years to recapture inpatient substance use disorder care going to 

the network. 

Army Medical Command conducted an analysis of all health care and pharmacy 

records involving Army Active Duty Servicemembers, reflecting an annual average 

population of 657,000 Soldiers from 2007 to 2012. This analysis showed a 65% increase in the number of Soldiers seeking behavioral health services (151,620 in 2007 

to 250,410 in 2012), and a corresponding 44% increase in the number of Soldiers 

prescribed any medication within the broad psychiatric category (101,914 in 2007 

to 147,197 in 2012). In other words, there has not been any disproportionate increase in medication use. There are multiple safeguards in place to ensure that psychiatric medications, including antipsychotic medications, are prescribed safely and 

judiciously according to accepted clinical practice guidelines and nationally recognized standards of care. 

MEDICAL HOME AND WARRIOR TRANSITION CLINICS

Optimizing the use of medications through pharmacist interaction as part of a Patient Centered Care Team is best exemplified by their work within the Wounded 

Warrior Clinics. Of the 22 Warrior Clinics in support of Army Medicine Warrior 

Transition Units, 21 Clinics are currently supported by approximately 25 clinical 

pharmacists and 5 pharmacy technicians. These Warrior Clinics are consistent with 

the Medical Home model, where pharmacists manage complex medication regimens 

and mitigate risks for Wounded Warriors. 

The Risk Assessment Management within the Warrior Care and Transition Program enables WTUs to monitor the safety of Soldiers. WTU Commanders, in coordination with the Soldiers’ interdisciplinary team, conduct risk assessments for every 

Soldier. The initial risk assessment occurs within 24 hours of the Soldier’s arrival 

at the WTU, ongoing assessments are regularly made throughout the Soldier’s stay, 

and additional assessments occur during key events such as during quarterly scrimmages as directed by the Soldier’s personalized Comprehensive Training Plan. Risk 

assessments focus on therapy adherence, behavioral health history, substance abuse 

history, and access to care patterns. The intent is to assess whether Soldiers on 

these medications need additional monitoring and assistance with medication management. If a Soldier is identified as needing additional monitoring and assistance, 

the interdisciplinary team determines what risk mitigation strategies are needed to 

maintain the Soldier’s safety. If needed, the Soldier is entered into the Army Medical Department’s Sole Provider Program. Soldiers enrolled in the Sole Provider Program may only receive medications from their assigned provider, and receive no 

more than a 7-day supply of narcotics or psychotropic medications. Clinical Pharmacists also provide oversight as they review the medication profiles of all Soldiers 

in a WTU, who are determined to be at high risk. These reviews occur at least 

weekly. 

Army Medicine has engaged in a comprehensive campaign to address the pain 

management needs of Soldiers and their Families. Our strategy involves developing 

and implementing solutions with our DOD, VHA, and Civilian Medicine partners. 

Thank you again for the opportunity to testify before the Committee and for your 

support to our Soldiers and Veterans. 

32 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. BERNARD SANDERS TO

BG NORVELL V. COOTS, USA, DEPUTY COMMANDING GENERAL (SUPPORT), U.S. 

ARMY MEDICAL COMMAND AND ASSISTANT SURGEON GENERAL FOR FORCE PROJECTION, OFFICE OF THE SURGEON GENERAL, U.S. ARMY

COMPLEMENTARY AND ALTERNATIVE MEDICINE (CAM)

Question 1. How can the Army improve access to CAM therapies among servicemembers? How can it help improve what information is available to servicemembers 

and their providers about CAM services? 

Response. In Army Medicine, perhaps the single greatest application of Complementary and Alternative Medicine (CAM) has been seen in pain management. 

Initially, Servicemembers were often the ones who identified integrative medicine 

treatments to their medical providers as uniquely effective in restoring and maintaining their health with minimal side effects. In response to this call to action and 

as a result of increasing medical evidence, Army Medicine has deliberately expanded 

its experience and utilization with integrative medicine as part of the Army’s Comprehensive Pain Management Program. 

The Army Pain Program has been moving toward a more multi-disciplinary, 

multi-modal pain management strategy that leverages selected CAM modalities 

alongside more conventional pain management treatments such as medications and 

interventional procedures such as injections, nerve blocks, and surgeries. In addition 

to chiropractic care, the Army’s Interdisciplinary Pain Management Centers are employing modalities such as acupuncture, massage therapy, movement therapies to 

include yoga, and biofeedback. These are all proving to be effective complements and 

sometimes alternatives to medications. 

Army Medicine will continue to expand the utilization and collection of evidence 

regarding the efficacy of integrative medicine modalities alongside more conventional therapies. 

Question 2. What factors currently limit DOD from further broadening CAM 

therapies across the Army and other branches? 

Response. Of the many treatment strategies addressed in the Army’s Comprehensive Pain Management Campaign Plan, the use of CAM therapies has been one of 

the most challenging. As noted in the Army’s 2010 Pain Task Force Report, there 

are an increasing number of reports in medical literature regarding the safety and 

efficacy of these treatment modalities, and their use is becoming more widespread 

across medicine. It is believed that the use of the various CAM modalities can lead 

to an improved sense of being, health status or functional outcome through pain reduction, lower medication usage or increased quality of life. However, there is still 

a paucity of evidence-based scientific literature on the precise role for these modalities in the overall management of acute and chronic pain. 

Per the Code of Federal Regulations, Section 199.4(g)(15), TRICARE is unable to 

pay for healthcare in the purchased care sector that has not been proven to be both 

safe and effective in the treatment of the underlying condition. While there have 

been an increasing number of articles published on the use of CAM for the treatment of acute and chronic pain, there have been no evidence-based clinical practice 

guidelines published or other evidence based protocols developed that incorporate 

the general use of CAM, or specific types of CAM. 

However, within the DOD, Military Treatment Facilities (MTFs) are allowed, 

under very specific conditions and specifications, to offer certain types of services 

that would otherwise not be covered benefits under TRICARE. That is the case with 

certain CAM therapies. Under these circumstances, the MTF Commander is responsible for ensuring that all existing community standards of care are met, to include 

any credentialing requirements of practitioners if they are not otherwise considered 

to be TRICARE authorized providers. Army Medicine is working with the Navy and 

Air Force to develop credentialing guidelines and oversight provisions to provide appropriate, standardized credentialing of practitioners who will employ CAM at our 

MTFs. 

One notable exception can be seen in the military’s expanded use of chiropractic 

care. Unlike the other CAM modalities, chiropractic care was originally offered in 

1995 as a demonstration program and later expanded as directed under Section 702 

of the National Defense Authorization Act (NDAA) for Fiscal Year 2001. Three subsequent NDAA’s allowed for expansion of the program, resulting in chiropractic 

services now being offered at 62 MTFs but still limited to Active Duty Servicemembers. 

33 

ACUPUNCTURE TRAINING

Question 3. How would the Joint Incentive Fund Project to implement a standardized acupuncture training and sustainment model across DOD and VA medical facilities improve acupuncture services the Army provides servicemembers? When can 

we expect system-wide implementation of this joint model? 

Response. The variances in acupuncture integration, utilization, reimbursement, 

and practice in health systems are not limited to Federal/military medicine. The absence of universally accepted protocols, credentialing, and clinical practice guidelines have inhibited more aggressive implementation across the DOD and VHA 

health systems. The $5.4 million, Joint Incentive Fund (JIF) acupuncture project 

will develop, pilot, evaluate and implement a uniform tiered acupuncture education 

and training program for Military Health System (MHS) and Veterans Health Administration (VHA) providers in order to provide initial and expanded access to this 

modality across MHS and VHA treatment facilities. 

The acupuncture JIF provides a pathway to uniform implementation and integration of this modality across military and VA healthcare systems through a proven 

practical program of training and certification for providers. It drives adoption and 

further development of acupuncture best practices across the MHS and VHA. The 

two-year acupuncture JIF project is scheduled to be completed by 2016. In progress 

reviews are provided to the Health Executive Council on a quarterly basis. 

Question 4. How many providers trained in acupuncture already working in the 

Army? How many of these providers exclusively offer acupuncture services? On average, how many hours per week do these offer acupuncture to servicemembers? 

Response. U.S. Army Medical Command (MEDCOM) providers, including physicians, physician assistants, nurse practitioners and dentists who wish to use acupuncture in their practice are required to document their acupuncture training and 

competency in their facility credentialing file. As of April 2014, 46 MEDCOM providers have added acupuncture to their credentialing files. None of these providers 

are exclusively offering acupuncture services but use acupuncture as a complementary modality in their practice. 

The number of hours per week where acupuncture is offered is not possible to calculate. However, the Army does capture the number of acupuncture procedure performance. In FY 2012, over 23,000 acupuncture procedures were performed in Army 

medical treatment facilities. The FY 2013 numbers for acupuncture utilization is 

currently unavailable but should trend upwards. 

The Army pain management program has been working to integrate licensed 

acupuncturists in the eight Army interdisciplinary pain management clinics. These 

individuals are being hired with a primary responsibility to provide acupuncture. At 

this time, the Army Pain Program, along with the Air Force, Navy, and VHA are 

working to standardize coding, treatment protocols, and credentialing for licensed 

acupuncturists. 

Question 5. Is the current amount of acupuncture offered within the Army sufficient to meet the demand for this therapy? If not, what efforts are being made to 

ensure an adequate number are available to treat veterans once the joint model is 

implemented? 

Response. The current capacity within the Army direct healthcare system is insufficient to support the perceived demand for acupuncture. 

While the Joint Incentive Fund acupuncture project to field a standardized basic 

acupuncture training and sustainment model across DOD and VHA will greatly improve access to basic acupuncture techniques, there will likely be a need for additional organized efforts to increase the enterprise wide training, availability, and 

utilization of acupuncture and other complementary integrative modalities. 

DOD/VA COLLABORATION

Question 6. What benefits has DOD seen from the standardization of the prescription medication between VA and DOD available to both servicemembers and veterans? Are servicemembers able to continue their existing course of treatment as 

they transition to VA health care? 

Response. Ongoing efforts to harmonize formularies are aimed at improving continuity of care for DOD beneficiaries transitioning to the VA. The VA has established policy that supports the continuation of DOD prescribed medications upon 

transfer whether or not the drug is listed on the formulary or if its use is consistent 

with VA prescribing guidelines. The VA provider is permitted to change previously 

prescribed medications to allow consistency with prescribing guidelines after careful 

consideration and implementation to prevent avoidable problems. 

34 

Question 7. What other efforts have DOD and VA taken to collaborate and standardize treatment options available to servicemembers and veterans for chronic pain? 

Response. Phased implementation of the Comprehensive Pain Management Campaign Plan is ongoing across Army Medicine and Tri-Service/VA implementation of 

Task Force recommendations continues as part of Health Executive Council Pain 

Management Work Group. In FY 2013, Army, Air Force, Navy, and the VA demonstrated increased interest and activity in synchronized implementation of Pain 

Task Force Recommendations. Uniformed Services and the VA will focus on executing several joint pain management projects as listed below. These projects will 

provide information to Defense Health Agency and Uniformed Services in order to 

facilitate re-evaluation and possible revisions of policies. 

a. Pain Management Outcome Tool 

b. Tiered Acupuncture Course for Primary Care Providers 

c. Development/Implementation of DOD/VHA education curriculum 

d. Synchronized DOD/VA transition policies for medications 

One specific project that highlights DOD/VA collaboration is the basic acupuncture training course. Army clinicians are participating with the Air Force, Navy, 

and VHA in a $5.4M Joint Incentive Fund Project to field a standardized basic acupuncture training and sustainment model across DOD and VHA medical facilities. 

Training teams have already started traveling to Army, Navy, Air Force, and VHA 

medical facilities to deliver this training. The response from providers and patients 

has been overwhelmingly positive. 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. RICHARD BLUMENTHAL

TO BG NORVELL V. COOTS, USA, DEPUTY COMMANDING GENERAL (SUPPORT), U.S. 

ARMY MEDICAL COMMAND AND ASSISTANT SURGEON GENERAL FOR FORCE PROJEC- TION, OFFICE OF THE SURGEON GENERAL, U.S. ARMY

Question 8. Do you have any further breakdown as to the usage for each of the 

branches of the Armed Forces? 

Response. Yes. Information is available on the usage of opiates for all branches 

of the Armed Forces. Question #9 and #10 responses provide information for Army 

Servicemembers. 

Question 9. How much of the opioid use is for acute conditions and for chronic 

conditions? 

Response. For acute conditions, the proportion of Active Duty Army Servicemembers prescribed an opiate medication at least once in a year for the last 10 

years is as follows: 

2004—21% 

2005—22% 

2006—25% 

2007—26% 

2008—26% 

2009—26% 

2010—27% 

2011—29% 

2012—29% 

2013—27% 

Chronic opioid use is defined as cumulative use of 90 or greater days of use in 

a six-month period. Information on chronic use is provided in the response to question #10. 

Question 10. How much opioid use is for >90 days in duration? 

Response. Chronic opioid use is defined as cumulative use of 90 or greater days 

of use in a six-month period. The proportion of Active Duty Army Servicemembers 

with any chronic opiate use in a year is as follows: 

2004—1.27% 

2005—1.54% 

2006—1.76% 

2007—1.96% 

2008—1.95% 

2009—1.97% 

2010—2.09% 

2011—2.36% 

2012—2.57% 

2013—2.34% 

35 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. MARK BEGICH TO BG 

NORVELL V. COOTS, USA, DEPUTY COMMANDING GENERAL (SUPPORT), U.S. ARMY

MEDICAL COMMAND AND ASSISTANT SURGEON GENERAL FOR FORCE PROJECTION, OFFICE OF THE SURGEON GENERAL, U.S. ARMY

Question 11. PTSD, depression, TBI, family stress, disability, and joblessness 

plague our veterans’ community and increase the risk of our veterans overmedicating to soothe chronic pain. How are you addressing growing mental health issues 

in conjunction with pain management? How does this initiative take into account 

rural and remote locations that may not have Behavioral Health professionals or 

telehealth? 

Response. In the past several years, the Army has vastly expanded and completely overhauled its system of behavioral healthcare and pain management program to address complex co-morbidities and co-occurring conditions.. The Army’s Behavioral Health Service Line is comprised of 11 interconnected standardized programs that provide consistent and ready access to behavioral health services covering all behavioral health conditions across our supported beneficiary population. 

The 2010 Army-led Pain Management Task Force was chartered to develop a 

strategy that is comprehensive, holistic, multidisciplinary, and multimodal, utilizing 

state-of-the-art/science practices in the field resulting in the Comprehensive Pain 

Management Campaign Plan. Army Medicine’s pain strategy includes three primary 

lines of effort: 1) implement a culture of pain awareness, education, and proactive 

intervention, 2) provide tools and infrastructure that support and encourage practice 

and research advancements in pain management, and 3) build a full spectrum of 

best practices for the continuum of acute and chronic pain, based on a foundation 

of the best available medical evidence. This includes incorporating behavioral health 

care as part of pain management solutions and ensuring pain management for Soldiers and pain management training for providers outside of the main area of care. 

Soldiers with complex injuries often require polypharmacy, or the use of multiple 

medications, which place them at greater risk for medication-related adverse events. 

The Army seeks to reduce risk, enhance safety and optimize care by including the 

Soldier, Family members, healthcare providers, pharmacists and commanders as 

part of the healthcare team. Army policies establish procedures to identify 

polypharmacy trends that could lead to misuse by Soldiers and Wounded Warriors. 

Army Medicine also uses best practices that are comparable to, or exceed, civilian 

programs, such as prescription drug monitoring to identify polypharmacy cases. 

Positive interventions include comprehensive medication reviews, sole provider programs, limiting the dispensed supply of medication, restricting high-risk patients to 

the utilization of one pharmacy, informed consent, use of non-drug treatment options, clinical pharmacist referrals, and patient and provider education. 

The Army trains its providers on the risks of prescription opioid overuse and ways 

to prevent medication misuse. Army Medicine has implemented systems and procedures our clinicians regularly use to prevent and detect issues of opioid overuse. 

These tools include the ability for our clinicians to review all prescriptions paid for 

by the Defense Health Agency (DHA) pharmacy benefit regardless of the point of 

service (Military, Home Delivery or Retail Pharmacy). 

The Army policy instructs healthcare providers to have a low threshold for referring patients to Behavioral Health resources and the Sole Prescriber Program. 

Healthcare providers enroll Soldiers at increased risk of adverse effects, drug interactions, or inappropriate medication use in the Sole Prescriber Program to optimize 

care. Once enrolled, only a Soldier’s designated provider or alternate provider is authorized to prescribe controlled substances for the Soldier. If necessary, the Soldier 

may be restricted to a specific pharmacy or pharmacies by activating the Prescription Lock-out Program. 

In addition to Soldiers who are identified as having intentional or unintentional 

risk for medication overdose, healthcare providers will refer Soldiers who present 

with polypharmacy-related concerns to a clinical pharmacist. 

Army Medicine is expanding the role of clinical pharmacists to address national 

concerns with polypharmacy and adverse drug events that lead to hospital admissions. The Army Surgeon General supports evidence-based enhancements drawing 

on the expertise and contributions of pharmacists embedded in Patient-Centered 

Medical Homes. 

Army Medicine has participated in all Drug Enforcement Agency (DEA) National 

Prescription Drug Take Back Day events since their inception in 2010. Thirty-six 

Army Military Treatment Facilities participated in the Take Back Day on 25 and 

26 October 2013, with over 2,000 patients participating and 7,491 pounds of unused 

medications collected. The Army will continue to participate in bi-annual Take Back 

events in an effort to maintain attention on the importance of appropriate disposal 

36 

of medications that are no longer needed. Army Medicine provides support through 

coordinated public affairs communications and education directed at medical staff, 

patients, Families and military leadership, to include on-site presence at every designated event. 

Specific to Telehealth, the Army has developed and vastly expanded a comprehensive Telehealth system over the past several years that now enables the Army to 

cross-level clinical care capacity across the globe. In fiscal year 2013, Army clinicians offered care across 18 time zones and in over 30 countries and territories, to 

include remote locations where Soldiers serve. In fiscal year 2013, Army clinicians 

provided over 34,000 patient encounters and provider-to-provider tele-consultations 

in garrison; approximately 85 percent of these encounters were related to outreach 

via Tele-Behavioral Health. 

The Army’s Pain Management Task Force recommended the Army ‘‘Expand telemedicine capabilities to incorporate pain management initiatives’’ (Pain Management Task Force, 2010). The Army Pain Management Extension for Community 

Healthcare Outcomes (ECHO) tele-mentoring initiative leverages the model developed by the University of New Mexico (UNM) Project ECHO initiative. The Army 

is completing a two-year collaboration with UNM to adapt this best practice for use 

in the Army’s pain program. ECHO’s objective is to complement the capacity, competence and confidence of remote primary care providers. Utilizing weekly video 

tele-conferencing to create regional communities of practice, ECHO links the IPMC 

specialty teams (i.e. hubs) with their designated Patient Centered Medical Homes 

(i.e. spokes). This improves provider knowledge, increases care coordination, and decreases the need for continued specialty referrals to the direct and purchased care 

systems. Army Pain ECHO will be available to Providers supporting Community 

Based Warrior Transition Units (CBWTU). Additionally, the Army is collaborating 

with the Air Force, Navy, and Veterans Health Administration on development and 

utilization of a common DOD/VHA Pain ECHO education curriculum. 

Chairman SANDERS. General Coots, thank you very much. 

Dr. Briggs. 

STATEMENT OF JOSEPHINE BRIGGS, M.D., DIRECTOR, NATIONAL CENTER FOR COMPLEMENTARY AND ALTERNATIVE 

MEDICINE, NATIONAL INSTITUTES OF HEALTH 

Dr. BRIGGS. Good morning, Chairman Sanders, Ranking Member 

Burr, and Members of the Committee. I want to add my well wishes to Senator Boozman. 

Thank you very much for inviting me. I am the Director of the 

National Center for Complementary and Alternative Medicine at 

the National Institutes of Health. NCCAM is the leading Federal 

agency responsible for research on the usefulness and safety of 

complementary and integrative health practices. 

The most common reason Americans turn to these health approaches is for treatment of pain. Pain is a major health problem 

affecting over 100 million Americans. It is one of the main drivers 

of our horrific national epidemic of prescription drug abuse. 

As a physician, I am well aware that drugs, including opioids, 

are absolutely essential for the management of pain but also of 

their serious side effects including overmedication dependency and 

even death. 

As a Nation, we need to find the appropriate balance between 

the substantial benefits of these medications and the risks. Deaths 

from opioids exceed those attributed to cocaine and heroin combined. Every day over 100 Americans die of drug overdoses, mostly 

from prescription painkillers. 

Opioids are particularly deadly when combined with Post Traumatic Stress Disorder; and as this Committee knows well, pain and 

PTSD is a common and tough combination faced by many veterans, 

also a very common problem in civilian populations. So, finding 

37 

better alternatives for pain management is an absolutely critical 

national need. 

Concern about research on better strategies for pain management is shared by leadership across the NIH. I serve as one of the 

co-directors of the Trans-NIH Pain Consortium and a member of 

the Federal Interagency Pain Research Coordinating Committee. 

Together with other Federal leaders, we are partnering to develop 

a cooperative research strategy to meet these important needs. 

Some of the very active areas of NIH research include the development of better pain measures including some of the measures 

that have been incorporated by the DOD, the PASTOR PROMIS 

measures, for example, understanding why acute pain sometimes 

turns into chronic pain, and the development of pain medications 

with less abuse potential. 

NCCAM’s particular focus is strengthening non-pharmacological 

treatment and self-management of pain. The evidence that some 

complementary approaches are of value in pain management is reflected in evidence-based guidelines from the American College of 

Physicians and the American Pain Society. 

Select practices including meditation, acupuncture, spinal manipulation, massage, and hypnosis are increasingly part of the kind of 

integrative care being offered in some of our health care settings, 

including hospitals, nursing homes, hospices, and most notably, 

health facilities in the Veterans’ Administration and Department of 

Defense. 

Integrative practitioners place particular emphasis on a patientcentered approach that identifies patient goals and, when appropriate, minimizes the use of drugs. 

Research on the mechanism and efficacy and safety of these approaches is the highest priority for NCCAM. We hope to learn how 

they work, who they help, and how they can be strengthened to 

better help people with chronic pain. 

As part of this effort, we have established a new intramural program that will study the biologic underpinnings of pain using stateof-the-art neuroscience methods to study the brain. 

We are particularly delighted to be embarking on an important 

partnership with the DOD and VA to support the value of these approaches to address the needs of military personnel and veterans 

for improvement non-pharmacological management of pain together with conditions such as PTSD, depression, and anxiety. 

We are funding new studies in partnership with the DOD, VA, 

National Institute on Drug Abuse, and the National Institute on 

Alcohol Abuse and Alcoholism on these important problems. 

We have created a working group of members of NCCAM’s advisory council to advise us on this research agenda. The working 

group includes distinguished DOD and VA officials such as former 

Army Surgeon General Eric Schoomaker and the VA’s Dr. Tracy 

Gaudet. It is chaired by Dr. Lloyd Michener, Director of Family 

Medicine at Duke University. 

In summary, Mr. Chairman, NIH and NCCAM are committed to 

partnerships with the VA and the DOD to strengthen research to 

understand pain, to improve pain management, and reduce overmedication and opioid dependency. 

38 

1 Nahin RL, Barnes PM, Stussman BA, et al. Costs of complementary and alternative medicine 

(CAM) and frequency of visits to CAM practitioners: United States, 2007. CDC National Health 

Statistics Report #18. 2009. 2 IOM (Institute of Medicine). 2011. Relieving Pain in America: A Blueprint for Transforming 

Prevention, Care, Education, and Research. Washington, DC: The National Academies Press. 3Drug Facts: Prescription and Over-the-Counter Medications, National Institute on Drug 

Abuse, National Institutes of Health, May 2013. http://www.drugabuse.gov/publications/ 

drugfacts/prescription-over-counter-medications, accessed April 28, 2014. 

Thank you. I am very happy to be here and happy to answer any 

questions. 

[The prepared statement of Dr. Briggs follows:] 

PREPARED STATEMENT OF JOSEPHINE BRIGGS, M.D., DIRECTOR, NATIONAL CENTER

FOR COMPLEMENTARY AND ALTERNATIVE MEDICINE, NATIONAL INSTITUTES OF

HEALTH, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Chairman Sanders, Ranking Member Burr, and Members of the Committee, 

thank you for inviting me to be here today to discuss the need to improve pain management strategies to reduce overmedication and opioid dependency. My name is Josephine Briggs, M.D., and I am the Director of the National Center for Complementary and Alternative Medicine (NCCAM) at the National Institutes of Health (NIH), 

the Federal Government’s lead agency for supporting scientific research on complementary practices and integrative health interventions. Our mission at NCCAM 

is to define the usefulness and safety of complementary and integrative health practices and their role in improving health through rigorous scientific investigation. 

Our research priorities are driven by scientific promise and public health need. We 

support the study of complementary interventions, approaches, and disciplines 

across the continuum of basic, translational, efficacy, and effectiveness research. 

Complementary, alternative, and integrative health practices are defined as having origins outside of mainstream conventional medicine. They include both self-care 

practices like meditation, yoga, and dietary supplements, and health care provider 

administered care such as acupuncture, and chiropractic, osteopathic, and naturopathic medicine. As these modalities are increasingly integrated into mainstream 

health care, NCCAM is committed to developing the evidence needed by the public, 

health care professionals, and policymakers to make informed decisions about their 

use and integration into medical practice. In addition to supporting the research, 

we disseminate the latest evidence-based information on these approaches to scientists, health care providers, and the general public through an information-rich 

Web site (www.nccam.nih.gov) and other media. 

According to the Centers for Disease Control and Prevention, approximately 30 

percent to 40 percent of Americans use complementary and integrative health practices, spending some $34 billion in 2007.1 This represents 1.5 percent of total health 

expenditures and 11 percent of out-of-pocket costs. These practices are increasingly 

being offered in hospitals and hospice settings. The most common reason cited for 

use of complementary and integrative health practices is for the alleviation of pain. 

Pain is a public health problem of substantial impact. It affects more than 100 

million Americans each year—more than the total affected by heart disease, cancer, 

and diabetes combined—and is estimated to cost the Nation $560-$635 billion each 

year in medical costs and lost productivity.2 While an important part of pain management, pharmaceutical approaches may provide incomplete relief and can carry 

serious side effects, including overmedication and opioid dependency and, in some 

cases, addiction. Commonly prescribed opioid pain relievers can be dangerous as 

even a single large dose can cause severe respiratory depression and death. Deaths 

from opioid pain relievers exceed those attributed to cocaine and heroin combined. 

Finding alternatives for pain management is needed.3

In 2011, after examining pain as a national public health problem, the Institute 

of Medicine (IOM) released a Consensus Report in 2011, entitled ‘‘Relieving Pain in 

America: A Blueprint for Transforming Prevention, Care, Education, and Research.’’ 

The IOM report encourages Federal and state agencies and private organizations to 

accelerate the collection of data on pain incidence, prevalence, and treatments, and 

to take steps to develop integrative pain management strategies. The report notes 

that ideally, most patients with severe persistent pain would obtain care from an 

interdisciplinary team using an integrated approach that would target multiple dimensions of chronic pain—including disease management, reduction in pain severity, improved functioning, and emotional well-being and health-related quality of 

life. 

39 

4 National Institutes of Health, National Institute of Neurological Disorders and Stroke, Office 

of Pain Policy. 2011 IPRCC Federal Pain Research Portfolio. Analysis Report. Available at 

iprcc.nih.gov/news/CC_Pain_Portfolio_Analysis_Report.pdf. Accessed April 28, 2014. 

In addition, the Federal Government created an Interagency Pain Research Coordinating Committee (IPRCC) to enhance pain research efforts and promote collaboration across the government, to advance our fundamental understanding of 

pain, and to improve pain-related treatment strategies. Members include representatives of the Departments of Health and Human Services, Veterans Affairs (VA), 

and Defense (DOD), the scientific and medical communities, the public, and stakeholder groups. I serve as one of the NIH representatives. The IPRCC is developing 

a comprehensive population health level strategy for pain prevention, treatment, 

management, and research. One of the first efforts of the IPRCC was a thorough 

analysis of pain research across Federal agencies, resulting in the recently released 

‘‘2011 IPRCC Federal Pain Research Portfolio Analysis Report’’ 4 which revealed 

many areas of shared research interests between and across Federal entities, but 

no notable redundancies. 

NCCAM participates in the NIH Pain Consortium to enhance and increase the 

coordination of pain research across NIH. The Consortium’s efforts include targeted 

initiatives such as the development of the first clinically-based data registry to help 

identify pain management interventions that are most effective for specific patienttypes with chronic pain, led by the National Institute on Drug Abuse (NIDA), and 

the creation of standard research measures to assess chronic low back pain, which 

was spearheaded by NCCAM. 

To improve pain education in health professional schools, the Pain Consortium established 12 Centers of Excellence in Pain Education to advance teaching and provide comprehensive curricula about the pathophysiology of pain, its assessment, diagnosis, management, and treatment. The curricula include the latest research results in complementary and integrative pain management, factors that contribute 

to both under- and over-prescribing of pain medications, and how pain manifests 

itself differently by gender, by age, and in diverse populations. In addition, NIDA, 

Medscape Education, and the White House Office of National Drug Control Policy 

developed two continuing medical education courses on practical guidance for physicians and other clinicians in screening pain patients for substance use disorder risk 

factors before prescribing, and in identifying when patients are abusing their medications. The courses use videos that model effective communication about sensitive 

issues, without losing sight of addressing the pain. To date, more than 80,000 health 

care professionals have completed these courses. 

At NCCAM, an increasing proportion of our research budget is dedicated to studies examining promising non-pharmacological approaches for pain management, including mindfulness meditation, spinal manipulation, massage, acupuncture, and 

exercise forms, such as yoga and Tai chi. Some of these approaches are already 

being recommended by the American College of Physicians and the American Pain 

Society in their guidelines for the diagnosis and treatment of low back pain. 

NCCAM is interested in better understanding how these interventions work, for 

what type of pain conditions, and the optimal methods of practice and delivery. We 

also support Centers of Excellence for Research on Complementary and Alternative 

Medicine that bring a multifaceted interdisciplinary approach to research on pain. 

In addition, NCCAM recently established a new intramural research program that 

focuses entirely on pain using state-of-the-art neuroimaging and other advanced 

technologies to study the mechanisms of pain including the role of emotions and attention on the modulation of pain. 

Last year, NCCAM joined NIDA, the National Institute on Alcohol Abuse and Alcoholism, and DOD in a joint initiative to conduct research on prevention and health 

promotion interventions to prevent alcohol and other drug abuse and associated 

physical and psychological health problems in Veterans and military personnel. 

NCCAM also issued a solicitation, along with NIDA and the VA, specifically focused 

on complementary and integrative approaches to managing pain and other symptoms such as posttraumatic stress, Traumatic Brain Injury, substance use disorders, 

anxiety, and sleep disturbances often experienced by Veterans and military personnel. The initiative requested research approaches to study (a) mind-body interventions such as mindfulness- or meditation-based stress reduction approaches, (b) 

yoga, (c) acupuncture, (d) art therapy, (e) massage, and (f) cognitive-behavioral 

interventions. Grant applications are currently under review, and we look forward 

to funding multiple studies later this year. Research findings from these initiatives 

are expected to lead to enhanced patient care and improved pain and symptom management through better integration of evidence-based complementary approaches. 

40 

At my direction, a special Working Group of the National Advisory Council on 

Complementary and Alternative Medicine was recently formed to explore ways to 

foster rigorous research that will inform the use and incorporation of complementary approaches in military and veteran populations and promote collaboration 

among the VA, DOD, and NCCAM. The Working Group, chaired by Lloyd Michener, 

M.D., of Duke University, includes current and former VA and DOD officials. The 

group is charged with defining a research agenda for mind/body interventions for 

pain and symptom management, including identifying the most promising therapies 

and the next steps for development of large clinical trials. Experts will present perspectives of patients, Veterans, military personnel, and clinicians to help shape the 

Working Group’s recommendations. 

In summary, NIH and NCCAM are committed to improving understanding and 

treatment of pain and related conditions for all Americans including military personnel and Veterans. We expect research results to provide information to the public 

and health care providers and policymakers. I appreciate the opportunity to appear 

before this Committee, and I look forward to answering any questions. Thank you. 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. BERNARD SANDERS TO

JOSEPHINE BRIGGS, M.D., DIRECTOR, NATIONAL CENTER FOR COMPLEMENTARY AND

ALTERNATIVE MEDICINE, NATIONAL INSTITUTES OF HEALTH

COMPLEMENTARY AND ALTERNATIVE MEDICINE (CAM)

Question 1. What can be done to increase long-term programmatic research to 

help better understand CAM therapies and their impact on servicemembers and 

veterans? 

Response. As the Federal Government’s lead agency for scientific research on complementary practices and integrative health interventions, the National Center for 

Complementary and Alternative Medicine (NCCAM) is committed to greater understanding of the usefulness and safety of complementary and integrative health practices and their role in improving health and health care. Since 2010, NCCAM has 

been working with the Departments of Defense (DOD) and Veterans Affairs (VA) 

to explore opportunities for partnerships and collaborations. 

After participating in workshops on complementary interventions for pain management with DOD and Post Traumatic Stress Disorder with VA, NCCAM issued 

a Funding Opportunity Announcement (FOA) in 2012, to encourage collaborations 

with DOD and VA researchers and clinicians to study integrative approaches to 

pain and symptom management in military and Veteran populations. Under this 

initiative, seven collaborations were funded to study modalities such as massage, 

acupuncture and chiropractic for musculoskeletal pain and post-traumatic headache, 

as well as Tai Chi and mindfulness for treating stress disorders, anxiety, and depression. In 2013, NCCAM participated in a FOA with the National Institute on 

Drug Abuse (NIDA) and DOD, to promote research on interventions to prevent alcohol and other drug abuse and associated physical and psychological health problems 

in military personnel and Veterans. NCCAM funded two research projects under 

this FOA, both involving the study of innovative interventions for pain management 

and to reduce substance abuse. 

Last year, NCCAM issued three FOAs, along with NIDA and VA, to encourage 

research on the non-pharmacological management of pain and co-morbid conditions 

in military personnel and Veterans. NCCAM has committed two million dollars in 

Fiscal Year 2014, and hopes to fund studies exploring a variety of complementary 

interventions for pain management, including combined interventions for treating 

pain and substance abuse, bright light treatment, mindfulness training, and the use 

of mobile neurofeedback applications for pain management. 

To guide future collaborative efforts with DOD and VA, NCCAM recently established a special Working Group of the National Advisory Council on Complementary 

and Alternative Medicine. The Working Group is charged with advising NCCAM on 

potential collaborations, opportunities and strategies for integrative health research 

within DOD and VA health care settings. Invited experts will present perspectives 

of patients, military personnel and Veterans, clinicians, researchers, and policymakers to inform the Working Group in shaping its final recommendations. The 

Working Group is expected to submit a report to the National Advisory Council for 

Complementary and Alternative Medicine in early 2015. 

NCCAM looks forward to building on current collaborations and continuing to 

partner with other NIH Institutes and Centers, DOD, and VA to further investigate 

the usefulness and safety of complementary and integrative health interventions for 

servicemembers and Veterans. 

41 

Question 2. A challenge of medical research is the length of time it takes for research to move from bench to bedside. What is the National Center for Complementary and Alternative Medicine doing specifically—and NIH more generally—to expedite this process? 

Response. NCCAM is committed to improving the translation of research findings 

into improved public health. At NCCAM’s core is a vision in which rigorous scientific evidence about complementary health practices informs both the decisions 

Americans make regarding the use of these health practices and their potential integration into health care. As such, NCCAM funds research across the continuum of 

basic, translational, efficacy, and effectiveness research. As part of our translational 

portfolio, NCCAM supports research required to design and implement definitive 

clinical research and ‘‘real-world’’ outcomes and effectiveness research that capitalizes on the reality that many complementary health interventions are in widespread 

public use. This research includes identifying and validating biomarkers or other 

signatures of biological effect; developing and validating measures of outcome; validating treatment algorithms and measures of quality control; and developing preliminary clinical evidence. 

Additionally, NCCAM is leading the Health Care Systems Research Collaboratory, 

an NIH Common Fund initiative. This program is engaging health care delivery organizations as research partners, with the goal of strengthening the national capacity to conduct rigorous large-scale clinical trials in ‘‘real-world’’ settings. Through 

the Collaboratory, NIH is pioneering the development of approaches to conduct 

large-scale, cost-effective clinical research studies in the setting where patients already receive their care. Ultimately, this program could help increase the number 

and types of health care systems engaged in clinical research and enhance the relevance of research results to health care practice. 

At the bedside-end of the continuum, NCCAM ensures that research results are 

widely disseminated to help the public make informed decisions about the use of 

complementary health practices and to enable health care providers to better manage patient care. NCCAM provides reliable, objective, and evidence-based information through a variety of approaches including emerging technology and platforms 

(i.e., video, social media, and mobile applications). Specifically for health care professionals, NCCAM’s web site features a portal with links to scientific literature on 

complementary health practices, including reviews from the Cochrane Collaboration; 

clinical practice guidelines issued by third-party organizations; and online continuing education modules. In addition, NCCAM’s monthly e-newsletter, NCCAM 

Clinical Digest, summarizes the state of the science on complementary health practices for specific health topics. 

Across the NIH, many NIH Institutes and Centers and trans-NIH initiatives are 

also focused on expediting the process of turning observations in the laboratory and 

clinic into effective interventions that improve the health of the individual and the 

public—from diagnostics and therapeutics to medical procedures and behavioral 

changes. For example, the newest Center at NIH, the National Center for Advancing Translational Sciences (NCATS) was established to transform this process by 

catalyzing the generation of innovative methods and technologies that will enhance 

the development, testing, and implementation of diagnostics and therapeutics across 

a wide range of human diseases and conditions. Advances from NCATS are aimed 

at enabling researchers throughout the public and private sectors to more efficiently 

develop treatments for diseases, demonstrate effectiveness in improving health, and 

accelerate the pace at which new treatments are delivered to patients. 

OPIOID USAGE

Question 3. How can collaborative efforts, such as the Interagency Pain Research 

Coordinating Committee, be leveraged to reduce the American health care system’s 

dependency on high-dose medications to reduce chronic pain and mental health conditions? 

Response. Collaborative efforts across the National Institutes of Health (NIH) and 

the Federal Government to increase the understanding of pain are helping to enable 

the development of novel therapies, including non-pharmacological approaches to 

treat those who suffer from pain conditions. Better strategies for the management 

of chronic pain may also reduce symptoms associated with some mental health conditions, such as depression and anxiety that are often comorbid with pain. 

The Interagency Pain Research Coordinating Committee (IPRCC) was created to 

enhance pain research efforts and promote collaboration across the Federal Government, with the ultimate goal of advancing fundamental understanding of pain and 

42 

1http://www.iprcc.nih.gov 

2DOD, VA, and within HHS, NIH, the Agency for Healthcare Research and Quality, the Centers for Disease Control and Prevention, and the Food and Drug Administration. 3http://www.nih.gov/news/health/may2014/nida–21.htm 

improving pain-related treatment strategies.1 The Committee comprises seven Federal members and 12 non-Federal members, six drawn from the scientific and medical communities and six from public and stakeholder groups. Six Federal Agencies 

are involved in this effort.2 NCCAM is one of the NIH representatives. 

The IPRCC conducted a thorough analysis of the Fiscal Year 2011 Federal pain 

research portfolio and released a report that identified areas for potential collaboration among the IPRCC- represented agencies. The analysis and accompanying report 

provide important tools to assist in sharing resources across the pain research community and for enhancing pain research efforts. For example, the Office of Pain Policy at NIH’s National Institute on Neurological Disorders and Stroke, under the 

auspices of the IPRCC, launched the Federal Government’s pain research database 

on May 27, 2014. This resource provides the public and the research community 

with an important tool to learn more about the breadth and details of pain research 

supported across the Federal Government. 

The IPRCC is also charged with developing the National Pain Strategy, a comprehensive population health level strategy for pain prevention, treatment, management, and research. One objective of the strategy is to describe how efforts across 

Government agencies, including public-private partnerships, can be established, coordinated, and integrated to encourage population-focused research, education, communication, and community-wide approaches that can help reduce pain and its consequences. The development of the National Pain Strategy will involve coordination 

between the IPRCC and the NIH’s Pain Consortium, as well as private-sector participants. 

Within the NIH, the NIH Pain Consortium helps coordinate and support a number of pain research initiatives and activities across the NIH. Importantly, the Pain 

Consortium is cosponsoring a workshop with the NIH Office of Disease Prevention 

to address several issues related to pain management, including the long-term effectiveness of opioids for treating chronic pain and the use and effectiveness of opioid 

management strategies in minimizing opioid addiction, abuse, and misuse, maximizing pain relief, and improving patients’ quality of life. Based on the evidence presented, an independent panel of experts will release a comprehensive report in early 

2015 on the state of the evidence, identifying research gaps and proposing research 

priorities. 

The efforts of the Pain Consortium have already made an impact. On May 21, 

2014, NIH announced that the NIH Pain Consortium’s first pain care curriculum— 

part of the 12 ‘‘Centers of Excellence in Pain Education’’—showed significant improvements in medical student clinical skills.3 The educational materials are designed to advance the assessment, diagnosis, and safe treatment of pain, while minimizing risks of abuse and addiction. The curricula include the latest research results in complementary and integrative pain management, factors that contribute 

to both under- and over-prescribing of pain medications, and how pain manifests 

itself differently by gender, by age, and in diverse populations. In addition, NIDA, 

Medscape Education, and the White House Office of National Drug Control Policy 

developed two continuing medical education courses on practical guidance for physicians and other clinicians in screening pain patients for substance use disorder risk 

factors before prescribing, and in identifying when patients are abusing their medications. The courses use videos that model effective communication about sensitive 

issues, without losing sight of addressing the pain. To date, more than 80,000 health 

care professionals have completed these courses. These efforts will help current and 

future health care professionals build clinical skills to better support, manage and 

treat patients with pain. 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. MARK BEGICH TO JOSEPHINE BRIGGS, M.D., DIRECTOR, NATIONAL CENTER FOR COMPLEMENTARY AND ALTERNATIVE MEDICINE, NATIONAL INSTITUTES OF HEALTH

Question 4. I know I hear from Veteran’s in my state that ask for more alternative 

methods for pain, PTSD and with our large native population, many native veterans 

rely on native healers, in the Native Health Care system, they are called doctors. 

Have you researched the use of Native healing and if not will you be looking at this 

effective method of healing? 

43 

4 Barnes PM, Bloom B, Nahin R. CDC National Health Statistics Report #12. Complementary 

and Alternative Medicine Use Among Adults and Children: United States, 2007. December 2008. 5http://www.nigms.nih.gov/Training/NARCH/Pages/default.aspx 

Response. NCCAM is committed to studying the usefulness, safety and efficacy of 

complementary and integrative health approaches, many of which have origins in 

traditional healing practices. Although a wide variety of these practices are used by 

the American public, better information is needed on how or whether they work. 

According to the Centers for Disease Control and Prevention, over 50 percent of 

American Indian/Alaska Native (AI/AN) adults use complementary therapies— 

greater than any other ethnic group.4 Given the prevalence of complementary therapies among this population, research on native healing practices is important, and 

NCCAM takes a number of approaches to encourage such research. For example, 

NCCAM is interested in research projects utilizing systems of healing and health 

practices outside the conventional medical care and those studying the extent and 

use of self-care and integrative health practices, conventional medical care, or a 

combination of the two. Examples of NCCAM funded research projects include: 

• ‘‘Drum-Assisted Recovery Therapy for Native Americans,’’ Daniel Lee 

Dickerson, D.O., MPH, University of California, Los Angeles. Dr. Dickerson’ grant 

focused on developing and pilot testing a treatment approach that included Drum 

Circles and the 12-steps of Alcoholics Anonymous within the conceptual framework 

of the Native American Medicine Wheel. 

• ‘‘Chemopreventative Properties of Medicinal and Food Plants of the Lumbee 

Tribe,’’ Tracie Locklear, Ph.D., University of Illinois, Chicago. Dr. Locklear’s grant 

supported her research on the development and testing of natural agents isolated 

from medicinal and food plants of the Lumbee Tribe. The long term goal of the 

project was to develop new and novel natural agents for the chemoprevention of 

breast cancer. 

In addition, NCCAM participates in the Native American Research Centers for 

Health (NARCH),5 which is a partnership between the Indian Health Service and 

NIH. The goal of the NARCH program is to provide opportunities for tribes and tribal organizations to conduct research, research training, and faculty development 

that meet the needs of AI/AN communities. 

44 

ADDITIONAL INFORMATION FROM JOSEPHINE P. BRIGGS, M.D., DIRECTOR, NATIONAL

CENTER FOR COMPLEMENTARY AND ALTERNATIVE MEDICINE, PUBLIC HEALTH SERVICE, NATIONAL INSTITUTES OF HEALTH


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Chairman SANDERS. Dr. Briggs, thank you very much. 

Let me begin with Dr. Petzel. Dr. Briggs, I think appropriately, 

talked about this issue as an epidemic. We have a horrific problem 

in Vermont but I think it is shared in States throughout this country. People overdosing, getting addicted, turning to crime, self-destruction. It is an awful issue. 

As we know, as bad as this problem is for the civilian population, 

it is likely even worse among our military and veteran population, 

largely because of the nature of the injuries and conditions they experience. 

Dr. Petzel, first, how serious is the problem you are addressing 

and second—Dr. Gaudet and maybe Dr. Marshall might want to 


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join in—tell me the role that you think complementary and alternative medicine can play in addressing those problems. 

Dr. PETZEL. Thank you, Mr. Chairman. 

First of all, in terms of the magnitude of the problem, several 

have mentioned it. We estimate that 50 percent of veterans that 

are coming to us seeking care have some sort of pain. Much of it 

is musculoskeletal, back injuries, et cetera, associated with the 

work that a soldier, sailor, airman, and Marine may be doing. 

We are prescribing opioids for somewhere around 650,000 veterans at the present time which is a large number of people, and 

we recognize the fact that this is an issue that has to be addressed 

very directly. 

I would like to just take a minute before I turn to the other panel 

members to describe the opioid safety program that we are involved in to try and get a grip on and reduce the use of opiates 

which, by the way, has reduced the number of patients receiving 

opioids in the last 18 months by 50,000. Still, there are a lot of people getting it but—— 

Chairman SANDERS. So, 50,000 fewer veterans are now receiving 

opioids? 

Dr. PETZEL. That is correct. 

The five things that are the central part of the pain management 

program are: one, every medical center has to have a pain management clinic; two, every medical center has a pain consultation service. VA requires the use of integrative CAM approaches. 

The details of this—we require the use of the step care model 

which was developed in the VA and I think has been adopted by 

the Department of Defense now which begins with, in the primary 

care clinic, self-management and management in primary care of 

pain. If needed, it moves to the secondary pain clinic; and then finally, there are tertiary pain services available. 

The centerpiece of this, though, is the opioid dashboard, monthly 

report to the facilities, to the providers in the facility, and to the 

pain management point of contact about people that are prescribing outside of the standard and patients that are taking medication outside of the standard. 

That is followed by education and discussion and consultation 

with the providers to bring their use of opioids into the standard. 

Chairman SANDERS. OK. If I can interrupt you, we will take a 

little bit more time for everybody, because we only have four of us 

here. But I wonder—if it is OK with you, Dr. Petzel, I wanted to 

shift over to Dr. Gaudet and Dr. Marshall. 

What are you doing with complementary and alternative medicine and is it, in fact, working? 

Dr. GAUDET. Thank you, Chairman Sanders. 

I think you are aware that the vision for health care, as Ranking 

Member Burr referenced, is personalized proactive patient-driven; 

central to that are strategies that are inclusive of complementary 

approaches that empower the veteran to take into their own hands 

whether they have pain issues. Of course, this expands far beyond 

pain to the many, many conditions facing veterans and the public, 

complex conditions where a simple fix does not exist. 

So, I think that these areas, particularly pain, are phenomenal 

places where the VA is committed to bringing more holistic apVerDate Mar 15 2010 19:16 Jul 24, 2015 Jkt 000000 PO 00000 Frm 00053 Fmt 6633 Sfmt 6601 Z:\ACTIVE\043014.TXT PAULIN
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proaches to veterans. The veterans are finding them very empowering, very much an asset to the complement of what they can do 

to address their issues of pain as well as other issues. Yes sir. 

Chairman SANDERS. In English. 

Dr. GAUDET. Yes, sorry. 

Chairman SANDERS. What are you offering the patient? So, somebody walks in. They have chronic pain. They are concerned about 

overmedication. You are concerned. What therapies are you offering and are they, in fact, working? 

These are fairly radical ideas in a certain sense, yes? Or not? 

Dr. GAUDET. I do not know how radical they are, but I think that 

the therapies that are most promising and most often utilized right 

now in the VA are very parallel to the DOD and the public. 

So, they tend to be mind-body approaches such as meditation, 

acupuncture, movement therapies such as, yoga, tai chi, spinal manipulation. These are the general approaches that seem to have the 

greatest promise—relatively noninvasive and at low risk. 

Chairman SANDERS. Now, I have been impressed. I have been to 

VA facilities all over the country and I have been to a couple of 

DOD facilities and I am amazed. You know, 20 or 30 years ago I 

think it is fair to say that if we were talking about this list of 

therapies, people would have thought there were a few folks in 

California or certain other places utilizing them, not the U.S. Department of Defense or VA. 

So, in terms of treatments like acupuncture, are they working? 

What can you tell us about your success rates? Does it work? 

Dr. GAUDET. I think the most evidence actually exists for acupuncture as it relates to pain. Our research office of evidence-based 

synthesis just finished a comprehensive look at all the evidence related to acupuncture. It is a very useful document because it basically says where is there evidence for the use of acupuncture, do 

we know, and is it of benefit or do we know it is not of benefit or 

there is a category where we just do not know yet, we do not have 

research. 

The areas where there is the best and strongest evidence for acupuncture are pain, chronic pain, headaches, and migraines. So, it 

is a rational place to start. 

Chairman SANDERS. All right. Dr. Marshall, if I walk into your 

beautiful facility in Minneapolis, and I was just there a few days 

ago, and I am in pain, what are my options other than drugs? 

Dr. MARSHALL. Mr. Chairman, thank you for that question. 

I would say at Minneapolis we view pain management as a fullspectrum opportunity to engage with a patient and move them toward a healthier and more functional life. 

So, we have deployed various complementary and alternative modalities at different levels of our facility. For instance, nurses, we 

trained 900 nurses in January of this year; a 4-hour training in 

complementary and alternative medicine with integrative nursing. 

Modalities that we trained specifically to those nurses included 

acupuncture, relaxation breathing, meditation, and essential oils or 

aroma therapy. 

Chairman SANDERS. When you tell your patients these therapies 

are available, do they say, hey, I would like to try that? What do 

they say? 

51 

Dr. MARSHALL. There is a lot of variability. Some patients, you 

know, express a strong desire for opioid pain medications. Many 

patients, though, are very open once they learn that these alternatives are a standard part of our medical treatment armamentarium at Minneapolis VA. I think many patients are gravitating 

toward these kind of services. 

Chairman SANDERS. Can you tell us some success stories? Are 

there people who have lived with pain, who were heavily medicated 

but because of complementary and alternative medicine have been 

able to get rid of medication? Dr. Marshall, do you have stories? 

Dr. MARSHALL. Yes, I would like to talk briefly about a program 

that we have just started. This is part of the VA’s efforts to have 

Council for Accreditation of Rehabilitation Facilities, CARF, pain 

rehab center at each VISN. So, we started one in January of this 

year. 

We recruited the Director of the Mayo Clinic Pain Rehab Program who is now leading our efforts. So that program which is just 

starting at Minneapolis VA had seven veterans, four of them were 

on opioids, three of them were tapered off, and one was tapered 

down. 

And a cornerstone of that program is a 3-week intensive residential program and a cornerstone of that program is activating patients’ innate healing abilities through use of primarily complementary and alternative modalities, including cognitive behavioral 

therapy, meditation, relaxation breathing, tai chi, yoga, and other 

active forms. 

Chairman SANDERS. So, you have some specific indications that 

these therapies are working? 

Dr. MARSHALL. Yes. 

Chairman SANDERS. OK. I have exceeded my time. 

Senator Burr. 

Senator BURR. Thank you, Mr. Chairman. 

Dr. Petzel, just one follow-up to this hope that we get a pathway 

on Phoenix to some facts. When we had one death at the Columbia 

VA medical center that was related to delays, when the medical 

center and the VISN leadership became aware of that problem 

there were four outside reviews, specifically the task force, the Office of Medical Inspector, and the IG. 

Are you confident that we have the sufficient focus on Phoenix 

for this Committee and for the VA to understand what, if anything, 

went wrong? 

Dr. PETZEL. Senator, I am. I think that the IG’s presence, the inspector general, with their independent look, and they have a huge 

collection of manpower that they are focusing. 

Senator BURR. What would trigger so many components for Columbia on one death versus just the IG on this? 

Dr. PETZEL. I really cannot answer that. I do not know. We sent 

our team in. I think the IG actually went in twice. I really cannot 

speak specifically to what they did. But I am confident that the IG 

has the resources and has them present in Phoenix to get to the 

bottom of what has occurred there. 

Senator BURR. OK. Dr. Gaudet, let me ask you. Is it easier to 

write a prescription or to try a CAM approach? 

Dr. GAUDET. It is easier to write a prescription. 

52 

Senator BURR. Yes. Can you envision, any of you from the VA, 

that it would be appropriate to prescribe an opiate to somebody 

who, in their medical records, has an opiate addiction? 

Dr. GAUDET. I am probably not the best person to answer that, 

not being a pain doctor. 

Senator BURR. Dr. Marshall? 

Dr. MARSHALL. I think the indications would be extremely rare. 

It would be very unusual to do that, but it might be done in certain 

situations, especially situations around acute pain from trauma 

after an operation. 

Senator BURR. So, for a veteran with an opiate addiction being 

treated by VA and sent home for the weekend with 19 prescriptions, including 12 tablets of oxycodone, and 3 hours later he dies 

of a drug overdose; that would be an unusual circumstance? 

Dr. MARSHALL. I would concur with your previous statement that 

one death too many. It should not happen. 

Senator BURR. Dr. Petzel, VA issued a pain management directive in 2009 and in a House Veterans’ Affairs Committee hearing 

last fall on the issue, Dr. Jesse said that all VISNs and VA facilities have implemented a pain management directive. Yet data obtained by the Center for Investigative Reporting shows, ‘‘VA doctors are prescribing more opiates than ever and the data suggests 

adoption of the directive varies widely.’’ 

This is not the only time we have heard problems about regulations and programs being executed inconsistently across the VA. 

What oversight does the VA central office perform to make sure 

that the new programs and directives issued are implemented as 

intended? 

Dr. PETZEL. Thank you, Senator Burr. 

One, the opioids safety initiative is intended to standardize the 

way we approach. Two, we have demonstrated that opioid prescribing in the VA has actually decreased, as I mentioned earlier, 

by 50,000 in the last approximately 18 months; and we expect to 

see that plummet. Number 3—— 

Senator BURR. We put this management plan into effect in 2009 

and we had an upward spike. You will agree to that? 

Dr. PETZEL. Yes. 

If I could digress for a minute. In this country in general, not 

just the VA, there was 10–15 years ago a feeling that pain was not 

being adequately managed, and an effort was made to educate doctors about using opioids and other things to adequately manage 

pain, and I think in this country there was an overreaction to that 

phenomenon. And that is part of why we are involved in this effort 

to try and get a grip on opioid prescribing and to aggressively pursue other approaches to managing pain. While I was not here at 

the time, my suspicion is that that was part of what was going on 

within the VA. 

Senator BURR. Well, I think Dr. Gaudet reinforced, I think, our 

belief, and I think it is the fact that it is easier to write a prescription than it is to go through a CAM process; and I think Dr. Briggs 

would probably agree with me. 

There are some medical conditions that we probably will not be 

able to use an alternative for. The pain is real. It is consistent. It 

can only be addressed with some type of opiate medication or alterVerDate Mar 15 2010 19:16 Jul 24, 2015 Jkt 000000 PO 00000 Frm 00056 Fmt 6633 Sfmt 6601 Z:\ACTIVE\043014.TXT PAULIN
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native to an opiate. For those people, they usually fall into a category of a specific illness that they have. Certainly, we do have 

some servicemembers that fall into that category. 

Here is my concern, Dr. Petzel, and my question is this, when 

people do not follow the guidelines set by VA—be it a doctor, nurse, 

whoever—what tools do you have to hold them accountable? 

I mean, we have seen difficulty with sterilization of medical devices. You and I have seen where insulin injection pens—multi-use 

injection pens—that we have now made a determination that we 

are not going to use them at the VA anymore because we—— 

Dr. PETZEL. No, they are not used in-patient. They are very, very 

deeply used as outpatients. They are great. 

Senator BURR. Why do we not use them in-patient? 

Dr. PETZEL. Because of the possibility that there might be confusion, as we talked about. 

Senator BURR. Because we cannot with certainty believe that it 

is being executed by those guidelines, which means you cannot 

stick a different person with the same pen. 

So, if something that simple is tough to do, what gives us confidence that we can carry out a pain management directive successfully or any other directive within the health care system? 

Dr. PETZEL. Senator Burr, I would point out that the opioid dashboard is our tool for monitoring the prescriber’s use of opioids. And 

the first step when somebody is not using these appropriately is to 

educate them about the way that it ought to be done properly. 

So, do we have the tools to correct behavior that we think needs 

to be modified? Absolutely yes. 

Senator BURR. OK, Mr. Chairman. Thank you. 

Chairman SANDERS. Thank you. 

Senator Begich. 

STATEMENT OF HON. MARK BEGICH, 

U.S. SENATOR FROM ALASKA 

Senator BEGICH. Mr. Chairman, thank you very much. I know 

earlier you talked about the issue in Arizona so I just want to know 

that—assuming that as soon as the IG report comes, and I know, 

Mr. Chairman, you noted that we will have some sort of process 

here. Obviously, we will look forward to that. 

The question that I am going to be very interested in, and it can 

be answered now or later, and that is the issue of the information 

that the Arizona VA was sending to the national, whatever the information was on appointment status; in other words, how long it 

took people to come through their appointments—that information. 

Was that correct or were there issues with it. That is going to be 

my question. 

There are a lot of details of deaths and so forth. What I want 

to know is did the information that came from the VA in Arizona 

to the national—who keeps track of successes at the different VAs 

and the amount of backlog and appointment scheduling—on those 

metrics, will that report or other reports confirm accuracy in the 

delivery of that information. That is going to be my fundamental 

question. 

Dr. PETZEL. Senator Begich, as I mentioned earlier, we had a 

team down there looking in a preliminary fashion at the cirVerDate Mar 15 2010 19:16 Jul 24, 2015 Jkt 000000 PO 00000 Frm 00057 Fmt 6633 Sfmt 6601 Z:\ACTIVE\043014.TXT PAULIN
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cumstances in Phoenix, and to date we have not found that there 

is any discrepancy between the information that we were aware of 

and were getting and the information as it actually existed in 

Phoenix. 

We have found no evidence for a secret list and we have not 

found any evidence to-date that anybody died while sitting on the 

waiting list. 

Senator BEGICH. Understood. And the IG is looking at all those 

questions I am assuming? 

Dr. PETZEL. Yes, they are; as near as I know, yes. 

Senator BEGICH. OK. And I apologize. I know this part was answered. What is their timetable? Do you know? 

Dr. PETZEL. They have not shared that with us, so I do not know. 

Senator BEGICH. OK. We will probably hear details as time 

moves on. 

Dr. PETZEL. I hope. 

Senator BEGICH. OK. Thank you. I missed one meeting—I cannot 

remember if I was here or at the Appropriations Committee—but 

I wanted again to commend you all for working on and reviewing 

the NUKA model in Alaska. 

We think this is—as we talk about overmedication and many 

other things—I think they have really capitalized on a very unique 

model that is looking at the whole body and all people engaged in 

health care. One of the things that I want to ask is, I am assuming 

in this issue today that we are talking about, overmedication, as 

you look at the NUKA model you will be also looking at this piece 

of the equation. 

For example, I know they use not only alternative medicines but 

they also use through the native health care, native healing methods. Is that also something as you look at the NUKA model you can 

be examining because I want to make sure that is part of the 

equation. 

Dr. PETZEL. My understanding, Senator Begich, is the central 

feature of the NUKA model is listening to the patient’s story and 

then crafting the therapy around that individual patient’s story 

and their circumstance. Since it is an Alaskan native program, 

those medicines, et cetera, are woven intimately into the way they 

deliver care. 

In the Native community here in the States where the VA is 

dealing, we also employ native healers, et cetera, and those concepts in dealing with that particular patient population. But I 

think Dr. Gaudet can maybe comment briefly on the fact that that 

is a tone that goes through our program. 

Dr. GAUDET. Yes, thank you, Senator. I would certainly just underscore the importance of this holistic approach which I appreciate 

your question actually brings to the surface. 

I think the challenge before us really—truly not just in VA 

health care but nationally in the model of health care that is dominant in this country—it is so much easier to write a prescription, 

as Ranking Member Burr said. 

The system is designed to do that. We as physicians are trained 

to find it-fix it. I can operate and I can write you a prescription and 

anything outside of that—and this is a slight exaggeration—but I 

am not actually trained to think about or understand. 

55 

So, this transformation is a huge system change, and it does as 

you have described and as Dr. Petzel has described, begin with understanding the person. If we are in a situation such as Senator 

Boozman, thank goodness we have the high-tech approach. Perfect. 

They can go in. We can sew you up. We can fix the problem. 

Senator BEGICH. Right. 

Dr. GAUDET. But in the myriad of things like pain, like obesity, 

like PTSD, those find it-fix it cures do not exist. So, this holistic 

approach starting with the individual, understanding their cultural 

beliefs and creating a personalized approach for and with them is 

absolutely essential. 

Senator BEGICH. Very good. Let me proceed, if I can, because I 

have limited time here. General, I know the Army and TRICARE 

have recently required mental health counselors to our veterans be 

credited through the Council for Accreditation of Counseling Related Educational Programs. 

Here is the challenge in Alaska. We do not have the capacity to 

meet those standards because of the uniqueness of Alaska. It is not 

offered in Alaska, so it makes it difficult; and with huge gaps in 

mental health professional numbers, how can we go with this when 

in reality we have vacancies that we should fill which can easily 

be filled with qualified counselors. But how are we going to meet 

this in Alaska? 

I mean, I know everyone likes a one-size-fits-all solution. Those 

do not work in Alaska. I will tell you there is no better health care 

as what the VA is looking—Indian Health Services—no better 

health care delivery system in the country. So, we figured out how 

to do it and it does not come from a national model. It does not 

come from the standards that people sit around and make up. 

I mean, we deal with reality. That is why we have a great dental 

program in the Indian Health Services. You know, the dental community does not necessarily like it totally, nationally, but it works 

in Alaska because we have remote areas and we have huge tooth 

decay and other things that we have been able to accomplish 

through dental therapists. 

So, how are we going to handle this? 

Chairman SANDERS. In 24 seconds. 

General COOTS. Yes, sir. Alaska is known for its use of tele-medicine initiatives, and I think that for the military utilizing tele-behavioral health is probably one of the biggest initiatives that we 

have in serving areas that are remote or where we do not have 

those health care providers. 

We are looking at some different ways of attracting additional 

behavioral health providers. We are also looking at training some 

of our own. As we draw down the military, we have a large core 

of physicians assistants that we are looking at retrainings some of 

them as behavioral health physicians’ assistants. 

Senator BEGICH. Very good. Let me say, Mr. Chairman, I have 

a couple of cases which I am going to send to Dr. Petzel and maybe 

some very specific questions on how we would respond to these 

kind of individuals that deal with medication. 

Thank you very much. 

Chairman SANDERS. Thank you, Senator Begich. 

Senator Isakson. 

56 

Senator ISAKSON. General Coots, first of all, thank you for your 

service particularly at Walter Reed. You all performed miracles on 

a daily basis in rehab for our servicemen. We appreciate it very 

much. 

I know Colonel Galloway’s responsibilities are rehabilitation and 

reintegration of DOD active duty troops back into society I take it 

or back into the military? 

General COOTS. Both. 

Senator ISAKSON. Which tells me that opiate overprescription is 

probably as big a problem in DOD as it is in veterans’ health care. 

Is that correct? 

General COOTS. Sir, I would say we have statistics that show 

that up until about 2011, about 26 percent of all active duty were 

on some level of opioid medications, either one single opioid or multiple opioids. 

The Army is traditionally a little bit higher, 2 or 3 percentage 

points higher, I think, by the nature of what we do and the pain 

that our servicemembers have from repeated combat tours in remote areas. 

But all the statistics are showing now that with a big push for 

cultural change, with integration of these alternative medical modalities, that we are seeing a downturn in opioid use across the 

military, particularly across the Army, and then a large upswing 

from 10 percent up to 28 percent now, utilizing alternative medicine. 

Senator ISAKSON. Which is my point because, you know, we use 

DOD for all kinds of medical research: breast cancer, prostate cancer, things like that because you have a controlled environment. 

You have people who are not necessarily voluntarily participating 

but they are participating because it is their job. We get a lot of 

medical data. 

I guess we have learned from addiction and opioid overuse that 

the ‘‘settled science’’ is there in terms of what constitutes an addiction or an overuse. What we are trying to do is find out how we 

deal with it, and once it happens, to prevent it from happening 

again. Is that right? 

General COOTS. Yes, Senator, that is correct. 

Senator ISAKSON. Then that brings me to my question. Seamless 

transition from DOD health care to veterans health care, which by 

the way General Schoomaker did a remarkable job of improving in 

his service at Walter Reed and in the military. 

What is DOD doing as these active duty military personnel go 

into veteran status? What is the transition like particularly with 

regard to opiates and then opiates having been prescribed, of them 

having been addicted? Is there a program or do they go into a black 

hole and the VA just has to discover the problem all for 

themselves? 

General COOTS. Senator, that is a good question. I will answer 

it in two parts. 

First, we have a shared formulary where we have lined up the 

formulary so that any medications that a military member might 

be on, as they transition into the veterans health care system, that 

same medication or modality is available to them in the transition. 

57 

We also are working on improving our warm handoff such that 

our military servicemembers have a lead coordinator. There is a 

corresponding lead coordinator on the VA side so that their information is transmitted directly in a handoff from that military lead 

coordinator to the VA system so that all of the associated and ancillary modalities that have treated them for whatever their problems are, be it opiate, be it anything else, all of those will transfer 

over so there is a knowledge transfer. 

So, there is no falling off in the cracks or going into a black hole. 

Senator ISAKSON. Good. Good. 

Dr. Marshall, the opioid safety initiative started in Minneapolis, 

is that right? 

Dr. MARSHALL. That is correct, Senator. 

Senator ISAKSON. If you uncover a provider who is not following 

the proper safety administration of opioid prescriptions, what training or what follow-up do you require to make sure that they do not 

do it again, or is there a prescription for doing that? 

Dr. MARSHALL. Well, first of all, Senator, thank you for that 

question because I think it is an integral part of what is happening 

at Minneapolis. So, we are building a standard of care and a cultural change in how we prescribe opioids. 

Part of it is building the prescribing of opioids into a team setting so we are using the providers who are doing the prescribing, 

the pharmacists who bring their unique skill set to the primary 

care team to help monitor for adverse effects or, you know, dosage 

problems, and also mental health. So, a lot of the control happens 

at that point working with the patient and the primary care team. 

Another phase of the accountability process is that we have 

transparent data—the dashboard that Dr. Petzel mentioned. So, we 

are using that to understand who are the outlying prescribers who 

need more help with changing their prescribing patterns. 

And the final stage of accountability rests with the chief of staff 

who, at our facility, has been very involved in providing specific direction to providers who are outside of the standard of care. 

So, it is a supportive system but there are levels of accountability. 

Senator ISAKSON. Dr. Petzel, you are familiar with our question 

with regard to suicide in the Atlanta VA, and I appreciate very 

much your attention to the ongoing initiative there. 

But it occurred to me that in the Atlanta VA situation where 

there were four instances now taking place over the last year, two 

of those were non-drug addicted Vietnam-era, noncombat veterans, 

meaning that they were veterans who served during the Vietnam 

era—my age group, in their late 60s or early 70s. They were not 

in combat. They did not transition from DOD to VA health care recently. They did it over a long period of time. 

I worry sometimes that prescribing opiates to mental health patients who come in for their first encounters at VA prescribing opiates might mask a greater problem or might accelerate a problem 

that exists. 

Is there any disciplinary requirements within the VA as far as 

mental health encounters are concerned in terms of prescribing 

opiates? 

58 

Dr. PETZEL. Senator Isakson, that is an excellent question. There 

are certain antecedents that are frequently found in patients who 

have either attempted suicide or actually committed suicide. Depression, PTSD, sleep disorders, and pain. Pain is often an antecedent to suicide, particularly chronic pain. 

So, the mental health provider is attuned to the fact that when 

they see somebody who is new to them that they need to be evaluated for those antecedents to be sure that they are taken into account when they begin to write prescriptions. 

So, anybody who has mental health problems who then also presents with a pain problem requires and gets very special attention. 

Senator ISAKSON. Thank you. 

Thank you, Mr. Chairman. 

Chairman SANDERS. Thank you, Senator Isakson. 

Senator Blumenthal. 

Senator BLUMENTHAL. General Coots, you mentioned a statistic 

before which I missed as to the percentage of use of opioids. I think 

that was the percentage in the Army or the military. Could you repeat that? 

General COOTS. Yes, Senator. Up to 2011, the number was about 

26 percent of all active duty had been prescribed at least one opioid 

medication. 

Senator BLUMENTHAL. And that could be in the course of the individual soldier’s entire service? Or over what period of time? 

General COOTS. We are actually tracking that on a year by year 

basis, watching it; and over time, say, from 2007 to 2011, you saw 

a steady increase up to that 26 percent point. After about 2011 

over the last 2 years, going on almost 3 years, we have seen a 

steady drop off, either stabilization or decline in the numbers that 

are using it. 

Senator BLUMENTHAL. So, let us take 2013. Over 2013, what percentage of active duty Army soldiers were prescribe some form of 

opioid? 

General COOTS. Senator, I do not have that exact number. 

Senator BLUMENTHAL. What is the last year for which you have 

a number? 

General COOTS. Sir, actually I do. It looks like about 24 percent 

or so, about 24 percent in 2013. So, down from 26 percent in 2011. 

Senator BLUMENTHAL. 26 percent in 2011 to 2013, 24 percent? 

General COOTS. Yes, Senator. 

Senator BLUMENTHAL. So, it is a pretty small difference. 

General COOTS. It is a small difference but I think it still represents a big cultural change and a move ahead because over the 

war years you saw a steady increase in it and the war is not yet 

over. We are still getting casualties although fewer; but over those 

last few years, we have been able to use these alternative modalities to include battlefield acupuncture. We use intranasal ketamine 

on the battlefield now which decreases the amount of morphine 

that you have to use. 

So, I think all of that is contributing as well in those complex 

casualties, and then translate that to our primary care clinics and 

our interdisciplinary pain management centers where we are implementing these alternative medications. I think all of that has 

been contributing to it. 

59 

So, we are right at the beginning of this cultural shift and this 

cultural change. 

Senator BLUMENTHAL. Let me just make sure that I understand 

that number. That is total active duty soldiers. 

General COOTS. That is total active duty. 

Senator BLUMENTHAL. 26 percent were prescribed some form of 

opioid in 2011 and 24 percent in 2013. That is not injured soldiers. 

It is all soldiers. 

General COOTS. That is all soldiers. This is all soldiers sailors, 

airmen, and Marines. That is all DOD. 

Senator BLUMENTHAL. OK. Let me ask you. You mentioned the 

warm handoff from active duty service to separation and VA treatment. As you probably know, many of us on this Committee have 

been concerned about the lack of interoperability of the Army medical records with the VA records in terms of the electronic medical 

record systems that each has. 

Do you see an effect of the lack of complete compatibility? I do 

not know what exactly the technical term would be, but I know 

that everybody is talking about trying to make it work better but 

still do not have an interoperable system. 

Do you see an effect of that? 

General COOTS. Actually, no, Senator. We are very compatible 

and very interoperable when it goes to that. There may be narrow 

pipelines between the two electronic health records but it still allows us to transition and transfer that critical information on complex patients and patients on—— 

Senator BLUMENTHAL. Is there an automatic re-evaluation when 

a soldier or an airman or Marine, or sailor goes from active duty 

to veteran status; re-evaluation of the prescription opioids? 

In other words, does somebody say, well, you have been getting 

this medication or that, let us have a look here. Maybe we need to 

do something different. 

General COOTS. To my understanding, there is an intake. Anytime you do a handoff or handover of a servicemember’s care into 

the veterans’ system, there is going to be an intake process. 

We transition all of that information from that one lead coordinator to the next. But certainly when they get in and they have 

a new provider, a new team who is taking over, there is a re-evaluation of everything that has happened in that servicemember’s 

medical history now than they have become a veteran. 

That does not necessarily mean there is a change in therapeutic 

approach or a change in modalities but it certainly could mean 

that. 

Senator BLUMENTHAL. It could mean it for an individual case. 

Let me ask Secretary Petzel whether he has any observations. 

Dr. PETZEL. Thank you, Senator Blumenthal. 

A comment on a couple of things. First of all, we have ready access to everything that is electronic in the DOD records. The interoperability part, we are working toward being sure that things 

mean the same in each kind of record. So, that is improving. It is 

definitely improving. 

Also the transition is improving with TAP, the Transition Assistance Program. We present to each one of the exiting servicemembers about what is available in DOD. People are often identified 

60 

now in that program that need to have a warm handoff. We are 

seeing much more of the at-risk patients being handed off to VA 

in a warm fashion. 

Senator BLUMENTHAL. Just so I understand, I use the term but 

what does that mean? 

Dr. PETZEL. That means there is a specific call to a VA medical 

center, this patient, John Jones, is transiting into the VA health 

care system. This is who he is. Here is what it means. We need 

an appointment for him. That is a warm handoff. 

What happens when they come to the VA—not all of them do, 

by the way. We need to understand that unfortunately we do not 

see as many people as we would like to see. They are evaluated. 

Our perspective as an organization is that we want to use the least 

risky, effective way of managing a patient’s pain. 

So that my hope would be and the expectation would be that 

their pain is evaluated. The medications that they are evaluated 

on, a plan is developed with that patient for the management of 

their pain that would again lead to the least risky, most effective 

way of managing their pain. 

Chairman SANDERS. I want to thank all of our panelists. This 

Committee considers the issue of overmedication to be a serious national problem, a problem within the VA and a problem within the 

DOD. We appreciate your focusing on it and the good work you are 

doing. So, thank you all very much. 

At this time I want to introduce our second panel. First, I am 

pleased to welcome Dr. Janet Kahn, who is a member of the Department of Psychiatry at the University of Vermont and Senior 

Policy Adviser for the Consortium of Academic Health Centers for 

Integrative Medicine. That is a mouthful. 

Then we have Dr. Mark Edlund, who is the Senior Research Public Health Analyst in the Behavioral Health Epidemiology Program 

at RTI International. 

Thank you both very much for being with us. 

Dr. Kahn, let us begin with you. 

STATEMENT OF JANET KAHN, Ph.D., RESEARCH ASSISTANT 

PROFESSOR, DEPARTMENT OF PSYCHIATRY, UNIVERSITY 

OF VERMONT AND SENIOR POLICY ADVISOR, CONSORTIUM 

OF ACADEMIC HEALTH CENTERS FOR INTEGRATIVE 

MEDICINE 

Ms. KAHN. Chairman Sanders, Ranking Member Burr, Members 

of the Committee, I want to thank you for the honor of testifying 

before this distinguished body on what we all agree is a really critical issue, the issue of overmedication, particularly overuse of 

opioids for pain management. 

I have been asked to share my understanding of what integrative 

health care approaches could offer to people in pain and people 

treating them. 

So, by way of background, I am a medical sociologist and for the 

past 30 years my work has focused on issues of integrative health 

care. I am also a clinician. I am a massage therapist and instructor 

of meditation and somatic awareness training. So, in that capacity 

in the treatment room what I have spent the last 30 years doing 

is trying to understand how people can move from illness to 

61 

wellness, from pain and ease, and how a nervous system that has 

gotten stuck in a flight or fight or freeze state can reset itself for 

optimal functioning. 

For the past 5 years, almost all of my work has been with veterans of OEF, OIF, and OND and their partners. I have seen them 

in my private practice; and with my research partner, William 

Collinge, we utilize a program called Mission Reconnect. 

This is a self-directed, home-use Web- and app-based program 

that offers instructions to help veterans and their partners learn 

various mind-body techniques that we know to support mental, 

physical, and relationship health. 

Preliminary research that was conducted with veterans of the 

Vermont and Oregon National Guard units showed 8 weeks of this 

program to be effective in decreasing pain, decreasing anxiety levels, and decreasing people scores on PTSD checklist measurements. 

We are now conducting a randomized clinical trial of Mission Reconnect in San Diego, Dallas, Fayetteville, North Carolina, and 

New York to understand the regional differences and to cover all 

branches of the military. 

The term ‘‘integrative medicine’’ has been used with various 

meanings, so, I want to be clear that when I speak of integrative 

health care, I use the term to refer to team-based, coordinated use 

of the most appropriate evidence-based interventions from across 

the full conventional, complementary, and alternative medicine 

spectrum, including preventive efforts and a particular focus on 

interventions that educate and engage the patient and his or her 

family members in their own care and, therefore, hopefully leaving 

them with skills for a lifetime. 

I think we all know the relevant reports from the Army Pain 

Management Task Force and the IOM, and I would like to echo 

those reports in calling for a comprehensive change not only in how 

we treat pain but literally how we think about pain so that it can 

guide the treatment beginning with understanding that we do not 

actually treat pain, we treat people in all their complexity, and 

pain is part of what they bring to the picture. 

So many of the men and women returning from these wars have 

multiple wounds. They have injuries to their bodies, to their brains, 

to their hearts, to their minds, to their spirits, to their relationships; and we need to find a way to deal with that complexity as 

we treat them because they need more than just having their 

symptoms quieted. They actually need help learning to heal and to 

lead fulfilling lives in the many decades, being young, that they 

have ahead of them. 

Our current approach to pain management can too easily lead to 

prescribing a drug for each identified problem and that in turn, as 

we know, can lead to a poly pharmacy problem that we may not 

have the capacity to actually manage. 

These veterans have already been asked to carry and maneuver 

with more weight in their packs than their bodies were designed 

for. They have been exposed to more stress than their nervous systems can manage as we see absolutely every day. So, over medicating them is no solution and no gift. 

There are evidence-based, non-pharmaceutical ways to address 

pain. In this kind of complexity, I suggest that we reorient toward 

62 

a positive vision of health and wellness for our veterans; try to 

come up under them. 

We know that lack of sleep, emotional stress, inability to take a 

deep breath, these things exacerbate pain. They literally make pain 

hurt more. They change the experience of it. 

So, addressing the building blocks of wellness can reduce the 

need for pain medication, and research clearly indicates that massage, acupuncture, yoga, and other mind-body therapies can significantly enhance sleep quality as well as duration, can help the nervous system rest down and thus reduce the experience of physical 

and emotional pain and alter the treatment needs for it. 

Educational interventions that include family members or groups 

of veterans can impart needed skills at the same time that they 

build community; and loss of community is an important element 

of a veteran’s pain. 

So, on top of all that they have already offered this country, veterans are offering us, I believe, the opportunity to embrace a 

wellness approach to the care of people who have incurred complex 

trauma, to kick our pharmaceuticals-only habit, come up with 

something more complex and interactive, and learn to collaborate 

across disciplines on their behalf. We should recognize this as one 

more gift they are giving us and move toward it quickly. 

[The prepared statement of Ms. Kahn follows:] 

63 

TESTIMONY OF JANET KAHN, PH.D., RESEARCH ASSISTANT PROFESSOR, DEPARTMENT

OF PSYCHIATRY, UNIVERSITY OF VERMONT AND SENIOR POLICY ADVISOR, CONSORTIUM OF ACADEMIC HEALTH CENTERS FOR INTEGRATIVE MEDICINE


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Chairman SANDERS. Thank you very much, Dr. Kahn. 

Dr. Edlund. 

STATEMENT OF MARK EDLUND, M.D., Ph.D., SENIOR RESEARCH PUBLIC HEALTH ANALYST, BEHAVIORAL HEALTH 

EPIDEMIOLOGY PROGRAM, RTI INTERNATIONAL 

Dr. EDLUND. Good morning. Thank you for inviting me. My name 

is Mark Edlund, and I am a health services researcher at RTI 

International and a practicing psychiatrist. 


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For the past 10 years my colleagues and I have researched patterns of opioid painkiller prescribing in Blue Cross/Blue Shield, Arkansas Medicaid, and more recently the VA. 

Our research involves analyzing administrative data and pharmacy records. Most recently, our research has focused on national 

patterns of opioid prescribing in the VA, supported by a grant from 

the National Institute of Drug Abuse. 

The VA data come from the years 2009 to 2011. My testimony 

today will provide initial findings from our NIDA-funded work. 

This work examined three aspects of opioid prescribing in the VA. 

One, rates of opioid prescribing in VA patients with chronic noncancer pain. Two, factors associated with discontinuation of chronic 

opioid therapy. And, three, factors associated with heavy utilization 

of opioids among VA patients with chronic pain. 

Rates of opioid prescribing in VA patients with chronic pain. 

Many VA patients have chronic pain, most commonly back pain 

and arthritis. Our results suggest that, among VA patients with 

chronic non-cancer pain who are using VA services at least twice 

per year, a little over half receive at least one outpatient opioid 

prescription in that year. 

Although comparing rates of opioid use between health care systems can be imprecise, this rate is approximately the same rate as 

found in other health care systems and in other health care plans. 

VA patients with chronic pain who receive opioids have a median 

of about 120 days of use in a year, that is, they used opioids about 

one 1 of 3 days—the median individual. This is generally higher 

than in other health care systems. 

In this same VA cohort, the median daily opioid dose is modest, 

about 21 milligram morphine equivalents. So, morphine equivalents are the way we standardize all these different opioids, and 21 

milligrams is fairly low. High would be thought of as, say, 120 to 

200. So, the median dose is generally lower in the VA than in other 

health care systems. 

Of the VA chronic pain patients prescribed opioids, the percentage who receive high doses of opioids is relatively small, about 5 

percent. This is also lower than in other health care systems. This 

is important because high dose is an important predictor of adverse 

outcomes. 

The opioid use of OEF/OIF VA patients has been the subject of 

scrutiny. We found that, among VA patients with chronic pain, 

OEF/OIF patients were less likely to be prescribed opioids as compared to other VA patients; and among VA patients with chronic 

pain who were prescribed opioids, OEF/OIF veterans were less likely to be heavy utilizers of opioids. 

Rates of opioid discontinuation. Among VA patients who received 

at least 90 days of VA opioids within a 180-day period in 2009, we 

looked at rates of discontinuation where discontinuation was defined as 6 months with no opioid prescription. 

We found that among these VA patients nearly 80 percent will 

receive years of opioid therapy. This is consistent with what we 

have found in analyses of other health care plans. While high daily 

doses is not common among VA patients, both high daily doses and 

use of long-acting opioids were strong predictors of opioid discontinuation, or excuse me, continuation. 

99 

Individuals with substance abuse disorders and mental health 

disorders were more likely to discontinue opioids in the VA. This 

is important because these patients are those who are at increased 

risk for opioid abuse. 

Factors associated with heavy opioid utilization among VA patients. In analyses of data from other health systems show individuals with substance abuse disorders are at a high risk for heavy 

utilization of opioids. 

However, in an analysis of VA patients with chronic pain known 

to be using the VA at least twice in a fiscal year, individuals with 

substance abuse were less likely to be heavy utilizers of opiates. 

In summary, while comparing health care systems can be imprecise, we found, one, among chronic pain patients rates of any opioid 

use is approximately the same in the VA and non-VA systems. 

However, among chronic pain patients in VA who receive opiates, 

the number of days for which they received opioids in a given year 

is generally higher than in non-VA systems. However, median daily 

dose in the VA is lower than in other health care systems. 

Finally, it appears that the VA does a better job of screening out 

individuals with substance abuse and mental health disorders from 

heavy utilization of opioids which is also very important because 

those are the people who are most likely to go on to abuse. 

[The prepared statement of Dr. Edlund follows:] 

PREPARED STATEMENT OF MARK J. EDLUND, M.D., PH.D., SENIOR RESEARCH PUBLIC

HEALTH ANALYST, BEHAVIORAL HEALTH EPIDEMIOLOGY PROGRAM, RTI INTERNATIONAL

Good morning, thank you for inviting me. My name is Mark Edlund. I am a 

health services researcher at RTI International, and a practicing psychiatrist. For 

the past 10 years my colleagues and I have researched patterns of opioid painkiller 

prescribing in different health care systems. Our research involves analyzing administrative data and pharmacy records. Most recently, our research has focused on national patterns of opioid prescribing in the VHA, supported by a grant from the National Institute of Drug Abuse (NIDA). 

My testimony today will provide initial findings from our NIDA-funded work. This 

work examined three aspects of opioid prescribing in the VHA: rates of opioid prescribing in VHA patients with chronic noncancer pain; factors associated with discontinuation of chronic opioid therapy; and, factors associated with chronic opioid 

use among VHA patients. 

Our research used VHA administrative and pharmacy data from years 2009 to 

2011. We have thus far conducted three different analyses of this data. The results 

from those analyses were reported at the Addiction Health Services meetings held 

October, 2013 in Portland, Oregon and the American Academy of Pain Medicine 

meetings held March, 2014 in Phoenix, Arizona. 

While some of the research methods were the same for all three studies, some 

methods varied in each study, as did the VHA patient sample. 

METHODS FOR ALL ANALYSES

Data Source 

We used data from three VHA Sources 

• Pharmacy Benefits Management Service (PBM) 

• VHA Corporate Data Warehouse 

• OEF/OIF roster 

Opioid Use Variables. Data included all opioid prescriptions (including date, daily 

dose, and type of opioid), other than injectable opioids and opioid suppositories (due 

to lack of conversion factors). We recorded the total number of opioid prescription 

fills for each patient within the fiscal year and calculated the number of days supplied for each patient in the year, as recorded by the dispensing pharmacist. The 

mean dose in morphine equivalents per day supplied for each patient was calculated 

100 

by summing the morphine equivalents for each prescription filled during the year, 

and dividing by the number of days supplied. 

Other Variables. We used International Classification of Diseases–9th Revision 

(ICD–9) codes from VHA Corporate Data Warehouse to construct variables for mental health diagnoses and substance use disorders. Chronic non-cancer pain conditions were also identified through ICD–9 codes and grouped into five broad categories encompassing the most common chronic noncancer pain conditions. These 

groupings included neck pain, back pain, arthritis/joint pain, headache/migraine and 

neuropathic pain, which are common to VHA patients. Demographic information 

such as age, race, gender and marital status were also extracted from the VHA Corporate Data Warehouse. 

IRB Approval. All analyses were approved by the Institutional Review Boards of 

The Central Arkansas Veterans Healthcare System and the University of Arkansas 

for Medical Sciences. A data use agreement was executed with each data repository. 

ANALYSIS 1—PATTERNS OF OPIOID USE FOR CHRONIC NONCANCER PAIN

Study Sample 

The study sample consisted of VHA patients in years 2009 to 2011 who met the 

following criteria. INCLUSION CRITERIA: 1) chronic noncancer pain diagnosis, as defined by two clinical encounters for the same chronic noncancer pain condition (neck 

pain, back pain, arthritis, headache/migraine, or neuropathic pain) at least 30 days 

apart, but no more than 365 days apart, 2) Received at least one opioid prescription 

during the year of chronic noncancer pain diagnosis, 3) Age 18 or older. EXCLUSION

CRITERIA: 1) Cancer diagnosis at any time in 2008–12 other than non-melanoma 

skin cancer, 2) resident of VHA nursing home or living in VHA domiciliary, 3) enrolled in VHA hospice benefits, 4) incomplete opioid prescription data, or 5) a prescription for a parenteral, suppository, or trans mucosal opioid. These criteria allow 

us to focus on VHA patients likely receiving opioids for the treatment of chronic 

noncancer pain. 

KEY RESULTS FROM FIRST ANALYSES

Many VHA patients have chronic pain, with the most common sources being back 

pain and arthritis. Our results suggest that, among VHA patients with chronic noncancer pain who are using the VA at least twice per year, a little over half receive 

at least one outpatient opioid prescription in that year. VA patients with chronic 

pain who receive opioids have a median of 120 days of use in a year, or about one 

out of three days. In this same VHA cohort the median daily opioid dose is modest, 

about 21 milligram morphine equivalents. 21 milligram morphine equivalents is 

fairly low, equivalent to about 2 Vicodin tablets. In our analyses the percentage of 

VHA patients who received high doses of opioids was relatively small—about five 

percent. Among VHA patients with chronic noncancer pain, 44% of all opioids were 

used by just 5% of patients; 1% of patients accounted for 17% of all opioids utilized. 

The opioid use of OEF/OIF VHA patients has been the subject of scrutiny. We 

found that, among VHA patients with chronic noncancer pain, OEF/OIF patients 

were less likely to be prescribed opioids compared to non OEF/OIF VHA patients, 

and less likely to be heavy utilizers of opioids. 

Conclusions: About half of all VHA patients with chronic noncancer pain receive 

opioids, and among those who receive opioids, the median days of use is 120 days. 

The median daily dose is modest. Total opioid use is heavily concentrated among 

a relatively small proportion of the VHA population with chronic noncancer pain. 

Second Analysis: 

Our second set of analyses focused on discontinuation from chronic opioid therapy. 

ANALYSIS 2—DISCONTINUATION FROM CHRONIC OPIOID THERAPY

Study Sample 

The study sample consisted of all adult VHA patients receiving 90 days or greater 

supply of non-parenteral opioids with less than a 30-day gap in supply within a 180- 

day period between January 1, 2009 and December 31, 2011. We refer to individuals 

who met these inclusion criteria as receiving chronic opioid therapy. The index date 

was defined as the first day of this 90-day period. A minimum of two prior encounters in the year preceding the index date were required to document routine use 

of VHA care. The year preceding the index period was used to identify additional 

exclusionary criteria and relevant co-variables. Veterans with an ICD–9 cancer diagnosis (with the exception of non-melanoma skin cancers) and administrative codes 

for VHA nursing home use, hospice or palliative care services in the 360 days before 

101 

and after the index date were excluded. Additionally, veterans with incomplete 

opioid prescription data (unknown dosages or types) or enrollment in a methadone 

maintenance program or receiving buprenorphine at any time were excluded. 

Given high rates of interrupted or episodic use among chronic opioid users and 

to maintain consistency in definitions, discontinuation was defined as the first runout day of a minimum 180-day period with no opioid prescriptions. In order to distinguish clearly between disenrollment from VHA and opioid discontinuation, participants without any VHA services use in the 90 days after discontinuation were 

excluded. 

If any two prescriptions overlapped by greater than 20% or greater than ten days, 

the overlapping portions of the prescription were assumed to be taken concurrently 

and the overlapping days were only included once in the opioid days calculation. If 

the overlap was ≤ 20% and ≤ 10 days the second prescription was shifted and the 

overlapping days from both the first and second prescription were included in the 

opioid days calculation. A dichotomous variable for the presence of multiple opioids 

defined as two or more types of opioids that overlapped by more than 30 days in 

any 40-day period was created as a surrogate for potential opioid misuse. 

VHA service utilization during the period of chronic opioid therapy was calculated 

as the total number of mental health encounters, substance use encounters and all 

other VHA encounters abstracted from Current Procedural Terminology (CPT) codes 

in the 90 days post-index. 

KEY RESULTS FROM ANALYSIS 2—DISCONTINUATION FROM CHRONIC OPIOID THERAPY

We identified 814,311 VHA patients who met our criteria for chronic opioid therapy. After exclusions were applied, 550,548 (67.6% of chronic opioid users) were eligible for analysis and 542,843 were entered into the statistical models. (We excluded 

7,705 (1.4%) of the sample due to missing data, primarily the absence of reliable 

rural/urban coding). The sample was primarily male (93%), white (74%) and urbandwelling (68%), with a mean age of 57.8 years and 52% were married. At one year 

after their index prescription date, only 7.5% of the sample had discontinued chronic 

opioid therapy. 

The majority of the sample suffered from at least one chronic noncancer pain condition (82.3%); just over a quarter of the sample had two chronic noncancer pain 

conditions (26.7%). Similarly, 62.3% of the sample had a mental health diagnosis, 

the most common being depressive disorder (29.7%). Only 14.5% of the sample had 

a substance use disorder, while 25.6% of the total sample used tobacco. The mean 

number of total clinical encounters in 90-days post-index was almost 9 (mean 8.92, 

SD 11.01). 

The mean daily morphine equivalent dose was 40.7 mg (SD 61.67 mg) among the 

VHA patients in this analysis though the median was 26 mg and only 7% received 

greater than 100 mg daily morphine equivalent. Nearly all received short-acting 

opioids (97.1%). Only 12.3% received multiple concurrent opioid prescriptions, usually a long-acting plus a short-acting opioid, and over half (57%) had received greater than 90 days total opioid supply in the year preceding their index date. 

We conducted analyses to examine factors associated with discontinuation from 

long-term opioid therapy. The maximum time available for follow-up was 1,279 days 

(3.5 years), and of those who discontinued (20%, N=110,460), the mean time to discontinuation was 530 days (SD 298.15, median: 465). The majority of the sample 

continued use through the end of the follow-up period. Demographic characteristics 

associated with higher rates of discontinuation of long-term opioid therapy included 

being younger or older than VHA patients aged 50–65 (0–30 years HR=1.52, 95% 

CI 1.47 to 1.57 and > 65 years HR=1.34, 95% CI 1.32 to 1.36), non-married status 

(HR 1.06, 95% CI 1.05 to 1.08) and African American race (HR 1.04, 95% CI 1.02 

to 1.06). Compared with VHA patients living in an isolated rural setting, those in 

an urban setting were significantly more likely to discontinue long-term opioid therapy (HR 1.08, 95% CI 1.05 to 1.10). 

VHA patients who were receiving higher average daily doses of opioids were less 

likely to discontinue chronic opioid therapy. Those taking long-acting opioid formulations had roughly 6% lower rates discontinuation of chronic opioid therapy compared with those taking short-acting opioid medications. (HR 0.94, 95% CI 0.90 to 

0.98 VHA patients). Those receiving multiple opioid prescriptions concurrently had 

about a 20% lower rate of discontinuation compared with VHA patients receiving 

only one opioid medication (HR 0.80, 95% CI 0.78 to 0.82). Finally, VHA patients 

with significant use of opioids in the year prior to the index date had almost a 30% 

lower rate of opioid discontinuations (HR 0.69, 95% CI 0.68 to 0.70). VHA patients 

who had multiple types of pain or who had greater level of medical comorbidity were 

more likely to continue chronic opioid therapy. 

102 

For the cohort of VHA patients in this analysis, mental health diagnoses were associated with greater likelihood of discontinuation of chronic opioid therapy, with 

schizophrenia and bipolar diagnoses associated with nearly 20% greater hazard of 

discontinuation (HR 1.20, 95% CI 1.16 to 1.25 for schizophrenia and HR 1.20, 95% 

CI 1.16 to 1.23 for bipolar). Alcohol use disorder (HR 1.10, 95% CI 1.07 to 1.12), 

opioid use disorder (HR 1.09, 95% CI 1.06 to 1.13) and non-opioid use disorders 

(HR 1.22, 95% CI 1.19 to 1.25) were all significantly associated with higher rates 

of discontinuation. In contrast to other mental health and substance use predictors, 

tobacco use disorders were associated with higher rates of continued long-term 

opioid therapy (HR 0.96, 95% CI 0.94 to 0.97). 

Conclusions: Among VHA patients who had received at least 90 days of opioids 

within a 180 day period in 2009, nearly 80% went on to receive years of opioid therapy. This is similar in other health care plans. However, in other health care plans 

we studied, individuals who were at high risk for opioid abuse, namely those with 

substance use disorders and mental health disorders, were more likely to receive 

high dose opioids and less likely to discontinue opioids. We generally did not find 

this in the VHA. As noted above, VHA patients with mental health diagnoses, diagnosed disorders related to alcohol use as well as opioid and non-opioid substance use 

disorders were more likely to be discontinued from long-term opioid therapy. Thus, 

it appears that VHA does better than other health care systems previously studied 

in terms of discontinuing patients from chronic opioid therapy. 

Third Analysis: 

Our third analysis examined factors associated with chronic opioid use among 

VHA patients who regularly used VHA care in FY 2011. 

ANALYSIS 3—CHRONIC OPIOID USE AMONG ALL VHA PATIENTS WITH OR WITHOUT

CHRONIC NON CANCER PAIN

Study Sample 

To be included in the cohort for the third analysis we identified all Veterans who 

had at least one outpatient opioid prescription in FY 2011 using data from the VHA 

Pharmacy Benefits Management Service. Similar to our 2nd analysis we used secure 

mechanisms to link the data from the Pharmacy Benefits Management Service to 

that of the Corporate Data Warehouse to identify VHA patients who used VHA care 

at least twice in FY 2011. VHA patients with an ICD–9 cancer diagnosis (with the 

exception of non-melanoma skin cancers) and administrative codes for VHA nursing 

home use, hospice or palliative care services, had codes for methadone maintenance 

or were receiving buprenorphine were also excluded from the sample. In addition, 

VHA patients receiving outpatient opioid prescriptions for injectable opioids, opioid 

suppositories or trans mucosal opioid preparations were also excluded from the 

analysis. VHA patients were not required to have a chronic pain diagnosis to be included in this sample. Based on these inclusion and exclusion criteria, we identified 

a total of 1,127,955 VHA patients who were using opioid medications in FY 2011. 

Almost 52% (584,765) of VHA patients in this analysis were using opioids for 91 or 

more days during that fiscal year. 

KEY RESULTS FROM ANALYSIS 3—CHRONIC OPIOID USE AMONG ALL VHA PATIENTS WITH

OR WITHOUT CHRONIC NONCANCER PAIN

In unadjusted results, chronic opioid users were slightly older than non-chronic 

users (59 years vs 57 years), were more likely to be white (72.9% vs 65.9%), and 

were less likely to be OEF/OIF/OND Veterans (5.9% vs 11.1%). 

We used a logistic regression model to identify factors associated with chronic 

opioid use in this cohort in FY 2011 (adjusted results). In this cohort, opioid use 

was most common in VHA patients ages 56 to 65 years; patients in other age groups 

were less likely to have chronic opioid use. The difference was most noticeable in 

the youngest age group. VHA patients ages 18–25 were almost 62% less likely than 

VHA patients ages 56–65 years to receive chronic opioid therapy (OR=0.38, 95% 

CI=.36–.39). Non-white VHA patients were approximately 28% less likely than 

white VHA patients to receive opioid medications chronically (OR=.72, 95% CI=.71– 

.73). VHA patients in whom race was unknown were also less likely to receive 

chronic opioid medications although the difference was less pronounced with these 

patients being 8% less likely to receive chronic opioid therapy compared with white 

patients (OR=.92, 95% CI=.90–.93). In this cohort women patients were 22% less 

likely to receive chronic opioid therapy compared with male patients (OR=.78, 95% 

CI=.77–.79). VHA patients who were identified as OEF/OIF Veterans were 34% less 

likely to receiving chronic opioid therapy compared with non-OEF/OIF Veterans 

(OR=.66, 95% CI=.65–.67). 

103 

In this cohort having PTSD or a depressive disorder was associated with receiving 

chronic opioid therapy. VHA patients in this cohort with a PTSD diagnosis were 

16% more likely to receiving chronic opioid therapy compared with VHA patients 

without PTSD (OR=1.16, 95% CI=1.15–1.18). VHA patients in this cohort with a diagnosis of a depressive disorder were 25% more likely to receive chronic opioid 

medications (OR=1.25, 95% CI=1.24–1.26). 

In this model, likelihood of chronic opioid use was most strongly associated with 

opioid dose, use of long-acting opioid medications and receiving multiple opioid 

medications concurrently. VHA patients in this cohort who were receiving 100MG 

morphine equivalent dose or more each day were 68% more likely to receive opioids 

chronically (OR=1.68, 95% CI=1.60–1.76. VHA patients who were receiving long-acting opioid medications were almost four times as likely to receive opioids chronically 

compared to those receiving short-acting medications (OR=3.77, 95% CI=3.6–3.8) 

while those receiving multiple opioid medications concurrently were more than 30 

times more likely to receive opioids chronically (OR=30.8, 95% CI=29.4–32.3). 

Conclusions: Of VHA patients who use opioids, about half use them chronically 

(at least 89 days per year). VHA patients who were non-whites, OEF/OIF, or female 

were less likely to receive chronic opioid therapy. Individuals with mental health 

disorders were more likely to receive opioids chronically, but the magnitude of this 

effect was small. Higher opioid dose, use of multiple opioids concurrently and use 

of long-acting opioid medications were strongly associated with chronic opioid use. 

CAVEATS

Our results should be interpreted with 4 factors in mind. First, we had access 

only to VHA records, and do not know about opioids VHA patients may be receiving 

outside the VHA system. Second, the definition of chronic pain is inherently subjective. In our first analysis we used a definition that is relatively strict. With less 

strict definitions, the percentage of VA chronic pain patients receiving opioids would 

likely be lower, as would the number of days of opioids used in a year. Third, the 

definition of high dose opioids is also subjective. We used a measure of high dose 

opioids that is on the low side. If we had used a measure that was higher, then 

our estimate of the percentage of VA patients with chronic pain who received high 

dose opioid therapy would have been lower. Fourth, although we reviewed records 

of all VHA patients in various years we included only specific patients in our analyses because we wanted to identify Veterans that were known to be using VHA care 

regularly. 

Thank you. 

Chairman SANDERS. Dr. Edlund, thank you very much for your 

testimony. 

Let me start with Dr. Kahn and just ask you a pretty simple 

question. Let’s say there is a veteran who is coming back from Iraq 

and Afghanistan dealing with pain issues, back pain or whatever 

it may be, he or she has difficulty sleeping, maybe the marriage is 

in trouble, they have difficulty holding on to a job. 

You said the issue here is not to deal with pain but to deal with 

the person. In the real world, somebody walks into your door with 

the issues I have described, the easy path is to medicate. Historically, we have done a lot of that. You have got pain; here are some 

drugs. 

You are proposing a different way. In English and maybe some 

concrete examples, what does that mean? What do you do with that 

individual who walked in your door? 

Ms. KAHN. So, I hope I made it clear that I am not suggesting 

an either/or approach. 

Chairman SANDERS. No. We understand absolutely. 

Ms. KAHN. OK. And I want to state clearly that I am not a physician. 

Chairman SANDERS. Right. 

Ms. KAHN. OK. So, that said, yes. I assume a physician would 

address issues of pain directly but at the same time because people’s experience of pain and their capacity to handle and to cope 

104 

with pain and manage whatever level of pain they are experiencing, is influenced by these other things like their general state 

of anxiety or whether or not they are sleep deprived and, therefore, 

on edge in a different way, we want to come up under them in 

terms of those elements of life at the same time as addressing the 

pain directly. That is what I am suggesting. 

Chairman SANDERS. Give me some examples, if you can, of the 

effectiveness of the approach you are utilizing. Does it work? Do 

you have some examples of people who have walked in the door 

who have been able to get effective treatment, see real improvements in their lives with minimal use of heavy drugs? 

Ms. KAHN. I think I am actually not in a position to answer that 

yet because in my own practice of offering Mission Reconnect to 

people the first trial with that program was not done in a VA context or in a medical context, thus I did not have access to medical 

records to be able to assess changes in medication prescription or 

use. 

We have been approached by psychologists at the Tampa VA, 

and they are in the process of preparing a proposal to look at exactly that, to apply Mission Reconnect with other care for people 

who are both high PTSD and high pain. 

Chairman SANDERS. OK. Dr. Edlund, do you have some thoughts 

on that? 

Dr. EDLUND. I think that these strategies are underutilized. I 

think that they hold promise. I think that they are particularly attractive in that they are noninvasive and they do not involve medication. 

I think that ultimately they are going to be an important part 

of the puzzle and there is no one piece of the puzzle that is dominant. So, I agree that all of these elements need to be brought to 

the fore. 

Chairman SANDERS. In your opinion, Dr. Edlund, has VA been 

aggressive in exploring these new approaches? 

Dr. EDLUND. I would say that the VA has been more aggressive 

than the rest of the American health care system and that the level 

of aggressiveness has markedly increased in the last 2 or 3 years. 

Chairman SANDERS. So, if you walked into a VA facility you 

would be more likely to have the option of looking at these approaches than in a private-sector hospital. Is that what you are 

saying? 

Dr. EDLUND. Yes, almost certainly. 

Chairman SANDERS. OK. Dr. Kahn, do you have anything to add 

to that? 

Ms. KAHN. Well, only that because in the non-governmental 

world, in the world of private insurance, most complementary and 

alternative medicine forms have not been and continue not to really be fully reimbursed. Then the patient is faced with a tougher 

choice if they are going to have to pay for it themselves in a private 

hospital than in the VA. So, I would imagine there would be greater use in the VA. 

Chairman SANDERS. Well, that is an interesting observation. So, 

because insurance companies do not cover many of these complementary or alternative approaches, the private hospital is constrained about what kind of therapies it can offer. 

105 

Ms. KAHN. Not necessarily what ones they offer but how they 

offer them. An increasing percentage of private hospitals do offer 

them, sometimes paid for philanthropically. Sometimes the hospital 

itself will pay and often it will be a fee that the patients themselves have to absorb. 

Chairman SANDERS. OK. Thank you very much. 

Senator Burr. 

Senator BURR. Mr. Chairman, thank you. 

The one thing that I hope I will not fall prey to is trying to practice medicine from this side of the dias. 

Chairman SANDERS. Give it a try. 

[Laughter.] 

Senator BURR. The truth is that the VA is a medical home and 

not everybody that prescribes in the private sector is necessarily 

that patient’s medical home. They are referred to that pain specialist by their medical home and I think a medical home is more 

apt to look at all the conditions that surround an individual before 

they make a determination as to which course to follow, and I 

think that is why maybe in the private sector there are options. 

I think the Chairman’s intent was to say that they are not all 

paid for by their insurance company where we have expanded it 

greatly in the VA. 

Dr. Kahn, I am fascinated to look at the studies once you have 

completed them in these multi-geographical areas with a variation 

of our active duty forces to see if we find variations between the 

Army and others. I look forward to that. 

But you testified that the VA needs to change from a problemfixing mentality to a more rounded approach toward health care, 

and I think you alluded to the fact that this is a big organization. 

There are a lot of people, and that makes it challenging. 

What do you see as those challenges? 

Ms. KAHN. Well, first of all, any big boat takes a while to turn. 

So, size is simply one problem. I do not know exactly what the level 

of acceptance right now is among providers across the VA so that 

would have to be assessed. 

In general, I would say in the field of health care across all 

health care professions—complementary, alternative, conventional, 

I would say many of us are fairly arrogant about our own approach 

and not necessarily even well informed about other approaches. 

Senator BURR. What do you see as the biggest impediment for 

VA making this transition? 

Ms. KAHN. I do not see anything insurmountable. I think if the 

will is there it can absolutely be done. I think in general we have 

not seen large-scale use of integrative health care. It has been sort 

of an almost boutique form, but I think the single largest civilian 

health system that is integrating across the whole system is Allina 

Health, which is in Minnesota and Wisconsin. It is not the 150 

medical centers and 1,500 clinics that the VA has. It is 12 hospitals 

and 150 clinics. But it begins to show the scalability, and I think 

the VA could do it. 

Senator BURR. Dr. Edlund, tremendous research comes out of 

RTI, and we are grateful for that, and thank you for your work on 

this. Your testimony discusses several research studies you conducted regarding the patterns of opiate prescribing in VA facilities. 

106 

Let me ask you, does RTI plan to conduct further research in 

that area? 

Dr. EDLUND. I am hoping to submit another grant, yes; and we 

have submitted grants in the past that have not been funded. So, 

yes, it is an active area of research. 

Senator BURR. Can you describe for us what you see that next 

research project structured like, that you would submit that grant 

for? 

Dr. EDLUND. Yes. The most recent grant that I have is actually 

not a VA grant. It is outside of the VA. Well, we will also be using 

VA physicians. 

We are looking at what goes into or how do physicians arrive at 

the decision to prescribe an opiate. Opiates are a two-edged sword, 

and the question is always how do you balance the risks and 

benefits. 

I am interested in understanding how they do that and what 

makes them decide along with the patient, OK, we are going to 

prescribe an opiate in this case or we are not going to prescribe an 

opiate in this case or we are going to escalate the opiate. 

So, these kind of fundamental decision-making processes that the 

physicians have to make along with the patient, we really do not 

understand at all and our next grant is to go in and try to better 

understand that. 

Senator BURR. Well, maybe, I can persuade Dr. Briggs for the 

Committee to answer that question that I believe she has probably 

looked at and it is a fascinating thing because I think we are making a big assumption that there is a tremendous amount of thought 

put into that determination. 

My observation would be opiates are prescribed a lot of times because that is what the patient came in and asked for, and doctors 

feel compelled to send them out with what, in fact, they requested. 

That may be part of our problem. 

I thank the Chair. 

Chairman SANDERS. Thank you, Senator Burr. 

Senator Blumenthal. 

Senator BLUMENTHAL. Thank you, Mr. Chairman. 

Dr. Edlund, this number may have been in your testimony but 

I have trouble seeing it highlighted there. Is there an average for 

the amount of time or the amount of drugs, opioids that are taken 

when they are prescribed? 

Dr. EDLUND. I am sorry. I am not understanding. Is there what? 

Senator BLUMENTHAL. Is there an average either period of time 

or amount of drugs over a period of time? In other words, someone 

who is prescribed an opioid takes it on average for 6 months, 2 

weeks, a year. 

Is there any data on how long the average prescription lasts? 

Dr. EDLUND. Yes. Well, what we know is that—we differentiate 

between acute opiate use and chronic opiate use. So acute use 

would be you hurt your ankle and that is not what we are talking 

about. 

But with chronic use, what we know is that once an individual 

has been on chronic opioids for about 90 days, then most of those 

individuals will go on to use opioids for years. Really, you know, 

107 

we cannot figure out and an average because at the end of 5 years, 

75 percent of them will still be on opiates. 

Senator BLUMENTHAL. Is there any data on whether the prescription for chronic users increases over time? In other words, does the 

amount of opioids prescribed have to increase to, in effect, take 

care of the same level of pain or for some other reason? 

Dr. EDLUND. No. That is a very good question and that is poorly 

understood, meaning whether or not in what percentage of cases 

the opioid dose can be stable. 

Definitely in some cases you have to increase the dose over time 

because the patient develops a tolerance and that is the whole 

problem with opiate use is that, you know, it is a spiral that is always going upward. But we do not know how many people are in 

a spiral going upward and how many people are relatively stable. 

Senator BLUMENTHAL. Is that not an important question? 

Dr. EDLUND. Yes. There are a lot of fundamental important questions in opioids that have not been answered. 

Senator BLUMENTHAL. I apologize for interrupting you but my 

time is limited; to follow up on Senator Burr’s excellent question, 

it may well be that the patient comes in and says I need more, Doc. 

Dr. EDLUND. It may very well be and I agree that a lot of times 

probably not a lot of thought is put into these decisions. 

Senator BLUMENTHAL. And is there a way, for example, to have 

trip wires, for a lack of a better word? In other words, after 6 

months there has to be a complete review by some independent 

medical professional or panel or some kind of authority to say, you 

know, there is a pattern here, increasing use over 6 months or, in 

other words, some kind of independent review. 

Dr. EDLUND. Yes. Obviously that could be done easily, but to my 

knowledge it is fairly rarely done. 

Senator BLUMENTHAL. And in your experience, to talk about Post 

Traumatic Stress—and I would ask this question of Dr. Kahn as 

well—Post Traumatic Stress, is that condition addressed therapeutically by opioid use or does opioid use address other conditions 

that, as Secretary Petzel said, may be found accompanied with Post 

Traumatic Stress, pain along with Post Traumatic Stress; is there 

an affect on the Post Traumatic Stress of using opioids either good 

or bad? 

Dr. EDLUND. I am not familiar with that research. I do know that 

a lot of people with PTSD receive opioids, but I cannot speak to the 

finding. 

Senator BLUMENTHAL. There is no research so far as you are 

aware—— 

Dr. EDLUND. Not that I am aware of. 

Senator BLUMENTHAL [continuing]. Showing the effects on Post 

Traumatic Stress, minus of opioid use? 

Dr. EDLUND. No, not that I am familiar with. 

Senator BLUMENTHAL. Dr. Kahn, are you aware of any such 

research? 

Ms. KAHN. No, I am not. 

Senator BLUMENTHAL. I would welcome—since I cannot ask the 

past panel whether they are aware of such research, if they are, 

please make me and perhaps the Committee aware of it. 

108 

I thank you, Mr. Chairman. Just one footnote here which I have 

said before. I refer to Post Traumatic Stress as Post Traumatic 

Stress rather than Post Traumatic Stress Disorder, and I had said 

it to others who have testified here including Secretary Shinseki. 

You may agree or disagree but I think it is important to remove 

the stigma of Post Traumatic Stress by not referring to it as a disorder. I may be clinically and medically out in left field but so be 

it. Thank you. 

Thank you Mr. Chairman. 

Chairman SANDERS. Senator Blumenthal, thank you very much 

and, Dr. Kahn, Dr. Edlund, thank you very much for helping us out 

on this very important issue. 

Ms. KAHN. Thank you. 

Chairman SANDERS. And with that, the hearing is now adjourned. 

[Whereupon, at 11:53 a.m., the Committee was adjourned.] 

(109) 

1 Excerpt ‘‘On the Edge’’ The American Legion Magazine story by Ken Olsen, April 1, 2014. 

2http://www.cbsnews.com/news/veterans-dying-from-overmedication/ 

3 Resolution #108: Request Congress Provide the Department of Veterans Affairs Adequate 

Funding for Medical and Prosthetic Research 

A P P E N D I X 

PREPARED STATEMENT OF THE AMERICAN LEGION

By the time Justin Minyard discovered the video of himself stoned, drooling and unable to help his daughter unwrap her Christmas presents, he 

was taking enough OxyContin®, oxycodone and Valium every day to deaden the pain of several terminally ill cancer patients. 

‘‘Heroin addicts call it the nod,’’ the former Special Forces soldier says of 

his demeanor in that video. ‘‘My head went back. My eyes rolled back in 

my head. I started drooling on myself. My daughter was asking why I 

wasn’t helping her, why I wasn’t listening to her.’’ 

Seeing that video jolted Minyard out of a two-year opiate stupor. He 

asked a Fort Bragg pain specialist to help him get off the painkillers his 

primary care physician had prescribed. ‘‘I was extremely disappointed in 

myself,’’ he says. ‘‘I knew I couldn’t do that to my family again.’’1

The preceding story is just one of many recent anecdotal accounts of veterans 

struggling with over-prescription of medications. In the best cases, the veteran in 

question has been able to pull themselves back from the brink, regroup, and work 

toward a different mode of care that doesn’t have the same devastating effect on 

the veteran and their families. In the worst cases, veterans have died from accidental overdose, or attempted suicide in a medication-induced haze. 

In September 2013, CBS news reported the tragic tale of 35 year old Army SPC 

Scott McDonald, who tragically perished from the accidental overdose brought about 

by the cumulative effects of the lengthy list of medications he had been prescribed.2

The American Legion believes these risks increase the importance of exploring Complementary and Alternative Medicine (CAM) therapies 3 that can reduce the overreliance on prescription drugs and help bring these veterans back from the brink 

of the abyss. 

The American Legion has continued to be concerned with the unprecedented numbers of veterans returning from the wars in Iraq and Afghanistan suffering from 

TBI and PTSD, categorized as the ‘‘signature wounds’’ of these conflicts. The American Legion believes that all possibilities should be explored and considered in an 

attempt to finding treatments, therapies, and cures for TBI and PTSD to include 

alternative treatments and therapies, and they need to make them accessible to all 

veterans. If these alternative treatments and therapies are deemed effective they 

should be made available and integrated into the veterans’ current health care 

model of care. 

As a result The American Legion established the TBI and PTSD Committee in 

2010 comprised of American Legion Past National Commanders, Commission Chairmen, respected academic figures, and national American Legion staff. The Committee is focused on investigating existing science and procedures as well as alternative methods for treating TBI and PTSD that are not being employed by the Department of Defense (DOD) and VA for the purpose of determining if such alternative treatments are practical and efficacious. 

During a three year study the Committee met with leading authorities in the 

DOD, VA, academia, veterans, private sector mental health experts, and caregivers 

about treatments and therapies veterans have received or are currently receiving for 

their TBI and PTSD symptoms. Last year the Committee released their findings 

and recommendations in a report titled ‘‘The War Within.’’ ‘‘The War Within’’ report 

110 

4 Resolution #108: Request Congress Provide the Department of Veterans Affairs Adequate 

Funding for Medical and Prosthetic Research 5 2011 SWS—‘‘Transition of Care from DOD to VA’’ 

6 2014 SWS—‘‘Past, Present and Future of VA Health Care’’ 

highlights these treatments and therapies and also identifies findings and recommendations to the DOD and VA. 

KEY HIGHLIGHTS AND FINDINGS OF THE REPORT: 

Some of the critical findings of The War Within included: 

• Most of the existing research for the last several years has only validated the 

current treatments that already exist—VA and DOD research is not pushing the 

boundaries of what can be done with new therapies, merely staying within an environment of self-confirmation bias. • There seems to be a lack of fast track mechanisms within DOD and VA to employ innovative or novel therapies—a standardized approach to these therapies 

could help servicemembers and veterans gain access to care that could help them. • While some VA medical centers (VAMCs) do offer complementary alternative 

medicine (CAM) therapies, they are not offered in a consistent or uniform manner 

across all 152 VAMCs nationwide—VA struggles with consistency and needs better 

guidance. 

In addition to those findings, the TBI and PTSD Committee made some recommendations for the way forward: 

• Congress needs to provide oversight and funding to DOD and the VA for innovative TBI and PTSD research that is being used successfully in the private sector 

healthcare systems such as hyperbaric oxygen therapy, virtual reality exposure 

therapy, and non-pharmacological treatments and therapies.4

• Congress needs to increase DOD and the VA research and treatment budgets 

in order to improve the research, screening, diagnosis, and treatments for TBI and 

PTSD. • DOD and VA need to accelerate their research efforts in order to effectively and 

efficiently diagnose and develop evidence-based TBI and PTSD treatments. 

CONTINUED EFFORTS: 

The American Legion’s efforts to assess the care and treatments available for veterans suffering from TBI and PTSD are not limited to the efforts of the TBI and 

PTSD Committee. In 2003, The American Legion established the System Worth 

Saving Task Force to conduct ongoing, on-site evaluations of the Veterans Health 

Administration (VHA) medical system. Annually, System Worth Saving visits provide Legionnaires, Congress and the public with an in-depth, boots on the ground 

view of how veterans are receiving their healthcare across the country. 

Over the last several years, the System Worth Saving reports have examined the 

full spectrum of VHA care, but specifically have noted several things about how 

VHA delivers on complementary and alternative medicine (CAM) in their facilities. 

VA medical centers throughout the VA healthcare system are committed, dedicated, and compassionate about treating veterans with TBI. Many medical centers 

throughout the country have found successful complementary and alternative methods for the treatment of TBI and PTSD such as hiking, canoeing, nature trips, 

equine, and music therapy.5 While some systems like the El Paso VA Healthcare 

System offer several CAM solutions, such as yoga, guitar lesions, sleep hygiene and 

other practices, other locations such as the Pittsburgh VA and Roseburg VA 

Healthcare System are more limited, offering only acupuncture in Pittsburgh, and 

acupuncture for pain management through the fee basis program in Roseburg.6

In addition to the ongoing System Worth Saving Task Force visits, The American 

Legion is taking the lead for veterans by aggressively pursuing the best possible 

treatment options for veterans on multiple fronts. 

HEARING FROM VETERANS ABOUT THEIR TREATMENT: 

On February 3, 2014, The American Legion launched a TBI and PTSD survey online in order to evaluate the efficacy of the veterans’ TBI and PTSD care, treatments, and therapies and to find out if they are receiving and benefiting from CAM 

treatment offered by the DOD and VA. The survey, conducted in coordination with 

the Data Recognition Corporation (DRC), Dr. Jeff Greenberg, Ph.D., and the Institute for the Advancement of Military and Veteran Healthcare, was to assist The 

American Legion to better understand the experiences of veterans who receive care 

throughout the VA healthcare system. 

111 

William Detweiler, Past National Commander and Chairman of the TBI and 

PTSD Committee has stated about the survey, ‘‘The American Legion is very concerned by the unprecedented number of veterans who suffer from these two 

conditions * * * We firmly believe that both VA and DOD need to act aggressively 

in adopting all effective treatments and cures, including alternatives being used in 

the private sector, and make them available to our veterans nationwide * * *. By 

completing this survey, veterans across America will have the opportunity to tell the 

true story of the types of care and treatments that they are actually receiving for 

PTSD and TBI. The survey will greatly help The American Legion in its efforts to 

advise the Administration, Congress, DOD, VA on the best possible care and treatments for these injuries.’’ 

The full survey results will be released and discussed in detail at the upcoming 

American Legion TBI and PTSD Symposium, June 2014, however two key data 

points emerged which bear special significance to this testimony. 

• Medication appears to be the front line treatment reported by respondents. 

• A sizable proportion of respondents reported prescriptions of up to 10 medications for PTSD/TBI across their treatment experience. 

Both of these data points should raise concerns about whether veterans are getting the right treatment for these signature wounds of the past decade’s wars. 

SYMPOSIUM: 

On June 24, 2014 in Washington, DC, The American Legion is hosting a TBI and 

PTSD Symposium entitled ‘‘Advancing Care and Treatment for Veterans with TBI 

and PTSD.’’ The symposium aims to discuss the findings and recommendations from 

the TBI and PTSD veteran’s survey, and will hear directly from servicemembers, 

veterans, and caregivers on their TBI and PTSD experiences, treatments and care. 

The symposium will also help us determine how the Administration, Congress, DOD 

and VA are integrating complementary and alternative treatments and therapies 

into current models of veterans’ health care. 

CONCLUSION: 

After a decade of war, America is still grappling with an evolving understanding 

of the nature of the wounds of warfare. Veterans must be reassured that the care 

they receive, whether serving on active duty in the military, or through the VA 

Healthcare system in their home town, is the best treatment available in the world. 

To combat the physical and psychological wounds of war, sometimes the old treatments are not going to be the most efficacious. 

Just as new understanding about the nature of these wounds emerges, so too 

must the new understanding about the best way to treat these wounds continue to 

adapt and evolve. Veterans are fortunate to have access to a healthcare system designed to treat their wounds, but that system must recognize that different treatments will have differing levels of effectiveness depending on the individual needs 

of the wounded veteran. There is no silver bullet. There is no single treatment guaranteed to cure all ailments. With a national policy that respects and encourages alternative therapies and cutting edge medicine, veterans have the best possible shot 

to get the treatment they need to continue being the productive backbone of society 

their discipline and training prepares them to be. 

Consider the following condensed version of one of the many veteran stories in 

The American Legion’s The War Within: 

Tim Hecker joined the Army at 18 and soon decided to make a career 

of it. He served 22 years in all, in and out of combat, rising to the rank 

of master sergeant. In the summer of 1990, he married his high school 

sweetheart, Tina, and the couple had three children. 

Then Tim couldn’t remember having married Tina. He couldn’t tell his 

sons apart. Their names escaped him. Injuries suffered in two separate 

roadside-bomb explosions in a span of two months in Iraq in early 2008 left 

him with a Traumatic Brain Injury and severe post-traumatic stress. He 

was no longer the man Tina had married. 

Frustrated with her husband’s descent and the lack of progress with traditional care, Tina went online and found information about hyperbaric 

medicine. Following a phone call and an initial interview, Tim was selected 

to be part of a pilot study on the use of hyperbaric oxygen therapy (HBOT) 

for Traumatic Brain Injury (TBI) and Posttraumatic Stress Disorder 

(PTSD). He claims the treatments have given him back most of his pre-injury life. 

112 

7http://www.legion.org/publications/217301/war-within-treatment-traumatic-brain-injury-andpost-traumatic-stress-disorder 

‘‘By the fourth treatment, I started feeling like a new person,’’ he says 

at his home in West Edmeston, N.Y. ‘‘I was more aware. I could see things. 

The deeper I got into the treatments, my cognition started to come back— 

my motor skills and my balance. My vision started to improve. The biggest 

benefit was my emotional control.’’ 

‘‘We’re talking a 180-degree turn around,’’ Tina says. ‘‘There are days 

when he’s almost back to normal with his personality.’’7

Ultimately, that is why it’s so important to ensure VA solves the over medication 

puzzle. The veterans have already returned home from war. This is about helping 

the veterans to finally return home to their families. 

The American Legion looks forward to working with the Committee, as well as 

VA, to find solutions that work for America’s veterans. For additional information 

regarding this testimony, please contact Mr. Ian de Planque at The American Legion’s Legislative Division, (202) 861–2700 or ideplanque@legion.org. 

PREPARED STATEMENT OF JOY J. ILEM, DEPUTY NATIONAL LEGISLATIVE DIRECTOR, 

DISABLED AMERICAN VETERANS

Chairman Sanders, Ranking Member Burr and Members of the Committee: DAV 

(Disabled American Veterans), an organization of 1.2 million wartime veterans who 

were wounded, injured or made ill due to their military service, appreciates this opportunity to offer testimony for the record of your hearing to examine overmedication and its problems and solutions in the Department of Veterans Affairs (VA). 

Less than a month ago, VA formally directed its 21 Veterans Integrated Service 

Networks (VISN) to launch a new and intensive opioid safety initiative. The stated 

goals are to reduce harm to veterans from unsafe medications and dosages, but to 

adequately control veterans’ pain. While DAV offers no opposition to this initiative, 

our experience in recent years in several local instances with VA physicians who 

decided to abruptly discontinue prescribed opioids for our members without offering 

them alternatives does not lend confidence that this initiative will be carried out 

with sensitivity to the needs of veterans to tolerably manage their pain in absence 

of such drugs. Some of our members who contacted DAV had been prescribed these 

drugs for decades, and were tolerating their pain well, but were offered little to no 

alternatives when VA physicians decided to abruptly end such prescribing. In situations such as these, we are concerned that these veterans will turn to alcohol or 

illicit drugs in search of pain relief, or will be left to needlessly suffer. 

As we understand it, VA’s opioid safety initiative contains nine goals. The initial 

goals (to be accomplished within six months, according to the directive) would establish systems to educate VA prescribers about safely and effectively prescribing 

opioids; increase the usage of urinalysis to detect presence of opioids in veterans’ 

urine; provide VA prescribers potential access to state prescription databases to 

identify veterans who are in receipt of opioids from private prescribers; and establish ‘‘tapering programs’’ for certain veterans using opioids along with other drugs. 

The second set of VA goals, to be achieved over the next nine months, includes 

central development of a ‘‘risk stratification toolkit’’ to be deployed locally in VA facilities to enable physicians to assess veterans using opioids who should not be 

treated with them, or identify those who can be given reduced doses at a safer level. 

Another goal calls for each VISN to implement a uniform tapering program for certain ‘‘high-risk’’ opioids, with an overall objective of VA’s achieving a 75 percent reduction in the use of certain opioids by not later than December 15, 2014. 

The third set of VA goals, to be achieved over a year or possibly longer, requires 

all VA facilities to identify veterans who are prescribed opioids above a stated dosage ceiling (200 milligrams of morphine equivalents per day). VA Central Office will 

collate this data and provide it to VISNs and facilities, which will be required to 

conduct appropriateness reviews with prescribers who are identified as providing 

veterans dosages higher than the dosage ceiling. Another goal is for all VA facilities 

to provide at least two unspecified complementary and alternative medicine (CAM) 

modalities in the treatment of chronic pain. These modalities are to be put in place 

by March 15, 2015. 

The last goal is to establish a mental health component within the Patient 

Aligned Care Team approach to delivering VA care to veterans with a history of prescribed opioid use, focusing on establishing a three-facility trial of deploying ‘‘interdisciplinary medication risk management teams,’’ to identify ‘‘strong practices that 

113 

can be operationalized across the VHA Healthcare System,’’ to achieve further reductions in the use of prescribed opioids. 

The above description of VA’s initiative is oversimplified and summarized for the 

Committee’s use, but constitutes our understanding of its purpose based on our review of the directive and information we have received from VA practitioners who 

remain concerned about this new program’s effectiveness and its impact on veterans 

in pain. To our knowledge neither DAV nor the remainder of the veterans service 

organization community have had a comprehensive briefing by VA on this new program, its purpose and justification, and how it will be implemented and monitored. 

It is also our understanding that, although already issued to VISNs and facilities, 

the directive is being reconsidered based on numerous concerns that have arisen 

since, and may be amended. 

While we have not received a national resolution from our membership on the 

topic of opioid reduction in VA health care, as indicated above, many of our members who were wounded, injured or made ill due to military service during wartime 

suffer from chronic pain from numerous causes other than malignancy (the only 

stated exception to this initiative), and presumably will be targeted by this new policy. The directive suggests that the use of CAM combined with integration of a specialized, and as yet untested, new mental health treatment model can substitute for 

existing prescribing practices by VA physicians who are dealing over time in primary and specialty care with veterans suffering from chronic pain and chronic pain 

syndrome. 

In a confounding countertrend, the Veterans Benefits Administration recently announced in the Federal Register that it has determined justification is sufficient to 

award service-connected ratings to veterans suffering from chronic pain and chronic 

pain syndrome, as discrete disabilities. DAV fully supports this broader authority 

to recognize that chronic pain is real, damaging and even debilitating. Also, this decision on rating veterans with chronic pain would suggest that chronic pain is a significant disabling condition from the vantage point of the VA division that awards 

disability compensation, whereas based on this new opioid reduction directive, another division of VA may see it quite differently. 

DAV is also concerned about VA’s potential participation in state drug monitoring 

programs. Many of these activities were stimulated by law enforcement, not public 

health authorities, in a search for illicit prescribing practices by private physicians, 

and trafficking in controlled substances by people who defraud physicians. While we 

appreciate VA’s legitimate interest in protecting against abuse and overuse of 

opioids, we are concerned about potential unintended consequences of VA’s approach 

to these state monitoring programs and recommend close oversight by the Committee to ensure its purposes are limited to the health and safety of veterans and 

of their health care. 

DAV would never advocate for broad use of narcotics as a first line, or only line, 

of treatment for wounded, injured and ill veterans with chronic pain or chronic pain 

syndrome; however, the intent of VA’s new initiative seems dedicated first to a drastic reduction in the use of painkiller drugs over other purposes, and may not keep 

uppermost the needs of veterans who suffer from chronic pain as a clinically legitimate treatment population. 

DAV strongly supports bringing significant CAM treatments into VA health care, 

particularly for younger veterans who do not want traditional health care, prescription medications or typical mental health treatments; however, if VA intends to use 

CAM as a substitute for, or replacement of, legally prescribed opioid medications in 

a known and older population, we urge VA to ensure the effects of shifting veterans 

away from these medications is closely followed in clinical care, lest these veterans 

resort to the abuse of alcohol or other drugs to compensate for the loss of painkillers 

that actually work for them. Additionally, VA facilities’ selection of CAM models 

may not have the desired effect intended by this directive. For example, a study in 

the Journal of the American Medical Association (‘‘Acupuncture for the Treatment 

of Cocaine Addiction: A Randomized Controlled Trial,’’ January 27, 2010) that followed treatment of a large group of cocaine users diverted to acupuncture therapy 

as a substitute did not demonstrate effectiveness in reducing the use of cocaine in 

that population. In fact, the study ‘‘does not support the use of acupuncture as a 

stand-alone treatment for cocaine addiction or in contexts in which patients receive 

only minimal concurrent psychosocial treatment.’’ Numerous other published studies 

replicate this finding on acupuncture, and are reported on VA’s Health Services Research and Development web page, http://www.hsrd.research.va.gov/publications/ 

esp/acupuncture.cfm. In our view, VA health care officials should carefully study the 

efficacy of CAM modalities as exchanges for prescribed opioids for pain to ensure 

they can accomplish the results intended, and that CAM modalities selected by faVerDate Mar 15 2010 19:16 Jul 24, 2015 Jkt 000000 PO 00000 Frm 00117 Fmt 6601 Sfmt 6621 Z:\ACTIVE\043014.TXT PAULIN
114 

cilities are efficacious for these purposes, are evidence-based, and are accompanied 

by appropriate other treatment resources. 

Mr. Chairman, perhaps most important to the purposes of this hearing, DAV is 

concerned that the required rapid implementation of this new directive will not be 

standardized and uniform across the vast VA system. In fact, the directive itself allows for local deviations and modifications, by ‘‘providing opportunity for 

customization to meet local needs.’’ The alternative approaches that are offered in 

the directive are vague, and may lead to wide variations, or only limited local implementation. In DAV’s view, the directive should mandate interdisciplinary pain management teams be established at each facility, and ensure these teams are functional, before launching such an aggressive tapering program. The structure and 

function of such teams should be specified and mandatory. Without more specificity, 

a ‘‘pain management team’’ may simply become a single provider designated in a 

facility whose primary (or imposed) clinical role would be to reduce the prescribing 

of opiates to veterans, without providing viable alternatives to address their pain. 

We believe any alternative treatments accompanying this plan should be specified 

and required in the directive. This availability should include psychological pain 

management treatments and other alternative treatments, including but not limited 

to specialized counseling, chiropractic care, and CAM approaches that are evidencebased. Even when some of these services are made ‘‘available,’’ a veteran with 

chronic pain may only be given a limited course of treatment, or be made to choose 

one or the other but not both to meet pain care needs. This would be an unfortunate 

and unsafe way to deal with opioid reduction due to its impact on the health of individual veterans. As an advocate for these veterans, especially those who were 

wounded, injured and ill due to military service, such an outcome would be unacceptable. 

During VA’s initiative to implement a national formulary 15 years ago, many prescribers complained that they were disallowed from prescribing preferred, standard 

medications they had used for years in their practices because they were not a part 

of the then-new national formulary. In order for VA physicians to procure off-formulary drugs under the policy, VA established a national procedure in which the 

prescriber had to submit an explicit justification for use of a particular drug in an 

individual veteran’s case, before a local or VISN VA pharmacy prescribing board, 

to gain approval of the deviation. This process at the time was seen as time consuming, a dampening influence, an interference of professional practice, and a difficult bureaucratic barrier. The formulary change accomplished the VA’s goal of producing cost savings, but it came at the expense of many veterans who needed to 

adjust to new medications without warning and in some cases against the interests 

of their prescribing physicians. We hope and trust this new initiative will not carry 

similar consequences for the veterans it is going to affect. 

Finally, also about 15 years ago, it is helpful to recall that VA took the national 

and even international lead on establishing pain as the ‘‘fifth vital sign.’’ Hospitals 

and physician practices all over the world now use this concept in evaluating patients’ pain level and developing interventions for pain as an important treatment 

goal on its own merit. Pain is the number one reason people, including wounded, 

injured and ill veterans, seek health care. DAV hopes VA will be able to carry out 

this new initiative to reduce opioid prescribing recalling its stewardship of pain 

management in western medicine, without rushing to judgment that veterans under 

VA care are atypically overprescribed narcotic medications. We understand from 

practitioners in VA facilities that, already, the pressure on, and monitoring of, providers to decrease their prescribing of opioids in pain management is leading to significant reductions in such prescribing, with no good alternatives available for affected veterans who are suffering from chronic pain. This is a troubling development, and we hope the Committee will thoroughly review this situation, not only 

during this hearing but on a recurring basis, to ensure that veterans experiencing 

pain remain VA’s primary focus. 

Mr. Chairman and Members, this concludes DAV’s statement. Again, DAV appreciates the indulgence of the Committee in permitting the submission of this 

testimony. 

115 

1Dr. Jackie Maffucci, IAVA’s Research Director, holds a Ph.D. in neuroscience from the University of Texas at Austin. She previously worked with the Provost Marshall General and other 

senior leaders at the Armed Forces Services Corporation to develop, implement, and monitor research programs and opportunities to address the health and wellness needs of servicemembers. 2Glantz, A. (2013, September 28). VA’s opiate overload feeds veterans’ addictions, overdose 

death. Center for Investigative Reporting. Retrieved from http://cironline.org/node/5261 3Government Accountability Office. (2012, November 14). DOD and VA Healthcare: Medication Needs during Transitions May Not Be Managed for All Servicemembers. Retrieved from 

http://www.gao.gov/products/GAO–13–26 4Kemp, J. and Bossarte, R. (2012). Suicide Data Report 2012. Department of Veterans Affairs. 

Retrieved from http://www.va.gov/opa/docs/suicide-data-report–2012-final.pdf 5 Ibid. 

6 Ibid. 

PREPARED STATEMENT OF JACQUELINE A. MAFFUCCI, PH.D.,1 RESEARCH DIRECTOR, 

IRAQ & AFGHANISTAN VETERANS OF AMERICA

Chairman Sanders, Ranking Member Burr, and Distinguished Members of the 

Committee: On behalf of Iraq and Afghanistan Veterans of America (IAVA), I would 

like to extend our gratitude for being given the opportunity to share with you our 

views and recommendations regarding overmedication, an important issue that affects the lives of thousands of servicemembers and veterans. 

As the Nation’s first and largest nonprofit, nonpartisan organization for veterans 

of the wars in Iraq and Afghanistan, IAVA’s mission is critically important but simple—to improve the lives of Iraq and Afghanistan veterans and their families. With 

a steadily growing base of nearly 270,000 members and supporters, we aim to help 

create a society that honors and supports veterans of all generations. 

In partnership with other military and veteran service organizations, IAVA has 

worked tirelessly to see that veterans’ and servicemembers’ health concerns are 

comprehensively addressed by the Department of Veterans Affairs (VA) and by the 

Department of Defense (DOD). IAVA understands the necessity of integrated, effective, world-class healthcare for servicemembers and veterans, and we will continue 

to advocate for the development of increased awareness, recognition and treatment 

of service-connected health concerns. 

A recent report from the Center for Investigative Reporting found that over the 

last 12 years, there has been a 270 percent increase in Veterans Health Administration (VHA) prescriptions for four powerful opiates.2 There has also been an increase 

in psychiatric medication prescriptions as well.3

Given the last 12 years of conflict and the very physical and psychological demands on our troops, it is no surprise that veterans are seeking care at the VA for 

a multitude of needs. The use of medication to treat certain physical and mental 

conditions is a valid treatment option, but the VA must continue to develop a comprehensive and multidisciplinary approach to treatment. 

The need for comprehensive treatment is particularly prevalent in polytrauma 

cases, which are among the most complex medical cases to address. Pain often presents in consort with other conditions, such as depression, anxiety, PTSD, or TBI. 

Providers can be challenged to treat such polytrauma cases because of the challenge 

of managing multiple conditions. Some of these conditions may limit the drugs 

available to the patient, making treatment options limited. 

These issues constitute major challenges for providers. Certainly part of a treatment program for chronic pain or mental health issues may include strong medication, including opioids and psychiatric medications; but a schedule of treatment 

should not be limited to pharmaceutical treatment and should integrate a host of 

other proven therapies. This is why a stepped case management system can be very 

helpful. In this type of system, a primary care physician has the support of an integrated, multi-disciplinary team of providers to design and implement a comprehensive treatment plan for the patient. 

With approximately 22 veterans dying by suicide every day, and more attempting 

suicide,4 reducing instances of overmedication and limiting access to powerful prescription medications that can be used to intentionally overdose must be included 

in a comprehensive approach to addressing the issue. Particularly considering that 

overdosing is a common mechanism for suicide attempts, with over half of all nonfatal suicide events among veterans resulting from overdose or intentional poisoning.5

The VA’s 2012 Suicide Data Report also showed that between 74–80 percent of 

servicemembers and veterans sought care from a provider within four weeks of attempting suicide.6 This evidence shows the critical need for providers to not only 

provide access to timely mental health services, but also to ensure that the risk of 

116 

overdose and overmedication are minimized through the use of state prescription 

monitoring programs and the creation of formulary take-back programs. 

Given the challenging nature of understanding the medical and mental health 

needs of veterans, the VA and the DOD have made laudable initiatives to meet 

these needs. But the challenge remains to uniformly and effectively translate all of 

these efforts to practice. Too often we hear the stories of veterans who are prescribed what seems like an assortment of psychiatric medications and/or opioids 

with very little oversight or follow-up. On the flip side, there are also stories of veterans with enormous pain and doctors who won’t consider their requests for stronger medication to manage the pain. 

One IAVA family member has expressed frustration and concern in regards to the 

VA’s current opioid drug usage. Her husband, who was prescribed nine different 

medications to address a range of health issues related to pain, anxiety, and depression, tragically passed away from what was labeled an accidental overdose by the 

corner. Since then, his widow has been fighting for overmedication by the VA to be 

included on his death certificate. 

In a similar case highlighted by CBS, a veteran with 5 tours of duty in Iraq and 

Afghanistan received a treatment plan from the VA with a total of eight prescriptions. When he was prescribed a ninth drug by the VA he took the medicine as instructed. The next morning he was found by his wife. His death was classified as 

an accidental death due to overmedication. His widow plans to sue the VA for his 

death. 

It is not our job to second-guess the judgment of the doctors treating these patients, but it is our job to question the system that is providing overall care to our 

veterans and tracking this care. The VA has established practices and policies 

aimed at providing quality care to veterans, but it won’t do our veterans any good 

if VHA cannot efficiently and effectively integrate these findings into their management practices and have a plan in place to continually improve upon accepted practice with evidence-based findings. While the VA has made great strides to recognize 

the need for comprehensive and multidisciplinary support, clearly there is still a lot 

of room for improvement in implementing these procedures. 

In part, some of the challenges may be in the inherent differences between the 

VA and DOD systems of care, whether it be in their available formularies, uniformity of record keeping and medical terminology used, or the interoperability, or 

lack thereof, of the medical record systems, care for our military and veteran population should be one integrated approach. A comprehensive treatment plan requires 

the VA and DOD have an integration of medical records such that receiving doctors 

are clear on the history of the patients that they intake. But beyond that, once the 

veteran is received into the VHA system, it’s not just about putting out policies, clinical practice guidelines, and funding research. At the end of the day, the success 

will be seen in how those products are implemented into practice and how they are 

continually assessed for effectiveness. The key will be in education, integration, and 

assessment. 

Again, we appreciate the opportunity to offer our views on this important topic, 

and we look forward to continuing to work with each of you, your staff, and this 

Committee to improve the lives of veterans and their families. 

Thank you for your time and attention. 

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