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41–375 2008

SUBSTANCE ABUSE/COMORBID DISORDERS: 

COMPREHENSIVE SOLUTIONS TO 

A COMPLEX PROBLEM 

HEARING 

BEFORE THE

SUBCOMMITTEE ON HEALTH 

OF THE

COMMITTEE ON VETERANS’ AFFAIRS 

U.S. HOUSE OF REPRESENTATIVES 

ONE HUNDRED TENTH CONGRESS 

SECOND SESSION 

MARCH 11, 2008 

Serial No. 110–75 

Printed for the use of the Committee on Veterans’ Affairs 

( 

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ii 

COMMITTEE ON VETERANS’ AFFAIRS 

BOB FILNER, California, Chairman 

CORRINE BROWN, Florida 

VIC SNYDER, Arkansas 

MICHAEL H. MICHAUD, Maine 

STEPHANIE HERSETH SANDLIN, South 

Dakota 

HARRY E. MITCHELL, Arizona 

JOHN J. HALL, New York 

PHIL HARE, Illinois 

MICHAEL F. DOYLE, Pennsylvania 

SHELLEY BERKLEY, Nevada 

JOHN T. SALAZAR, Colorado 

CIRO D. RODRIGUEZ, Texas 

JOE DONNELLY, Indiana 

JERRY MCNERNEY, California 

ZACHARY T. SPACE, Ohio 

TIMOTHY J. WALZ, Minnesota 

STEVE BUYER, Indiana, Ranking 

CLIFF STEARNS, Florida 

JERRY MORAN, Kansas 

HENRY E. BROWN, JR., South Carolina 

JEFF MILLER, Florida 

JOHN BOOZMAN, Arkansas 

GINNY BROWN-WAITE, Florida 

MICHAEL R. TURNER, Ohio 

BRIAN P. BILBRAY, California 

DOUG LAMBORN, Colorado 

GUS M. BILIRAKIS, Florida 

VERN BUCHANAN, Florida 

VACANT 

MALCOM A. SHORTER, Staff Director 

SUBCOMMITTEE ON HEALTH 

MICHAEL H. MICHAUD, Maine, Chairman 

CORRINE BROWN, Florida 

VIC SNYDER, Arkansas 

PHIL HARE, Illinois 

MICHAEL F. DOYLE, Pennsylvania 

SHELLEY BERKLEY, Nevada 

JOHN T. SALAZAR, Colorado 

JEFF MILLER, Florida, Ranking 

CLIFF STEARNS, Florida 

JERRY MORAN, Kansas 

HENRY E. BROWN, JR., South Carolina 

VACANT 

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

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

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

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

between various electronic formats may introduce unintentional errors or omissions. Such occurrences are inherent in the current publication process and should diminish as the process 

is further refined. 

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C O N T E N T S 

March 11, 2008 

Page 

Substance Abuse/Comorbid Disorders: Comprehensive Solutions to a Complex 

Problem ................................................................................................................. 1 

OPENING STATEMENTS 

Chairman Michael H. Michaud .............................................................................. 1 

Prepared statement of Chairman Michaud .................................................... 42 

Hon. Phil Hare ......................................................................................................... 2 

Hon. Shelley Berkley, prepared statement of ........................................................ 42 

Hon. John T. Salazar, prepared statement of ....................................................... 43 

WITNESSES 

U.S. Department of Veterans Affairs, Antonette Zeiss, Ph.D., Deputy Chief 

Consultant, Office of Mental Health Services, Veterans Health Administration ........................................................................................................................ 23

Prepared statement of Dr. Zeiss ...................................................................... 59 

Disabled American Veterans, Joy J. Ilem, Assistant National Legislative Director ..................................................................................................................... 13 

Prepared statement of Ms. Ilem ...................................................................... 50 

Iraq and Afghanistan Veterans of America, Todd Bowers, Director of Government Affairs .......................................................................................................... 17 

Prepared statement of Mr. Bowers ................................................................. 58 

McCormick, Richard A., Ph.D., Senior Scholar, Center for Health Care Policy 

and Research, Case Western Reserve University, Cleveland, OH ................... 4 

Prepared statement of Dr. McCormick ........................................................... 47 

NAADAC, the Association for Addiction Professionals, Patricia M. Greer, 

President ............................................................................................................... 2 

Prepared statement of Ms. Greer .................................................................... 43 

Vietnam Veterans of America, Thomas J. Berger, Ph.D., Chair, National 

PTSD and Substance Abuse Committee ............................................................ 15 

Prepared statement of Dr. Berger ................................................................... 54 

SUBMISSIONS FOR THE RECORD 

American Legion, Joseph L. Wilson, Deputy Director, Veterans Affairs and 

Rehabilitation Commission, statement .............................................................. 61 

Miller, Hon. Jeff, Ranking Republican Member, and a Representative in Congress from the State of Florida, statement ........................................................ 63 

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(1) 

SUBSTANCE ABUSE/COMORBID DISORDERS: 

COMPREHENSIVE SOLUTIONS TO 

A COMPLEX PROBLEM 

TUESDAY, MARCH 11, 2008 

U.S. HOUSE OF REPRESENTATIVES, COMMITTEE ON VETERANS’ AFFAIRS, SUBCOMMITTEE ON HEALTH, Washington, DC. 

The Subcommittee met, pursuant to notice, at 10:00 a.m., in 

Room 334, Cannon House Office Building, Hon. Michael H. 

Michaud [Chairman of the Subcommittee] presiding. 

Present: Representatives Michaud, Berkley, Hare, and Salazar. 

OPENING STATEMENT OF CHAIRMAN MICHAUD 

Mr. MICHAUD. I call the Subcommittee to order, and ask our first 

group of panelists to please come to the table. 

I would like to welcome everyone to our Subcommittee hearing 

today. We are here today to talk about treatment for substance 

abuse and comorbid conditions within the U.S. Department of Veterans Affairs (VA). 

Substance use disorders (SUDs) are among the most common diagnoses made by the Veterans Health Administration (VHA). According to the 2007 National Survey on Drug Use and Health, 7.1 

percent of veterans met the criteria in the past year for a substance use disorder. And 1.5 percent of veterans had a co-occurring 

substance use disorder. 

Of the approximately 300,000 veterans from Operation Enduring 

Freedom (OEF) and Operation Iraqi Freedom (OIF) who have 

accessed VA healthcare, nearly 50,000 have been diagnosed with 

substance use disorder. Additionally, more than 70 percent of 

homeless veterans suffer from alcohol and drug abuse problems. 

Over the past several years, Congress has increased funding for 

substance use treatment programs within the Department of Veterans Affairs to $428 million in fiscal year 2008. I believe that continuing adequate funding is imperative for the health and wellbeing of our veterans and their families. 

Substance use frequently co-occurs with other mental health conditions. VA needs to continue to dedicate itself to providing services 

that can address both substance use and other mental health conditions such as post traumatic stress disorder (PTSD) simultaneously. 

I also was pleased to learn that Dr. Kussman, VA’s Under Secretary for Health, recently released a directive on the management 

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of substance use disorders. This directive states that, among other 

things, VA facilities must not deny care to any enrolled veteran because they are using substances. And that all VA medical facilities 

must provide services to meet the needs of veterans with substance 

use disorders and PTSD. 

I think that this is a step in the right direction. I commend VA 

for its proactive leadership on this. 

Last week, Mr. Miller and I introduced the ‘‘Veterans Substance 

Use Disorder Prevention and Treatment Act of 2008.’’ The Subcommittee realizes that substance use and comorbid conditions are 

complex issues. But we also recognize that it is important and that 

this deserves serious thought and consideration. 

I look forward to hearing from our panels today about the ways 

that the VA can effectively address these critical issues. 

[The prepared statement of Chairman Michaud appears on p. 42.] 

Mr. MICHAUD. And now I would like to recognize Mr. Hare for 

an opening statement. 

OPENING STATEMENT OF HON. PHIL HARE 

Mr. HARE. I will be very brief. Thank you, Mr. Chairman. I want 

to thank you for holding this hearing and the continuance of hearings that you have organized about veterans mental healthcare. 

Substance use disorder and its comorbidity with post traumatic 

stress disorder are clearly a significant health issue among our returning veterans. And while it is crucial that we must understand 

what needs our veterans have, I believe that we must act quickly 

to ensure that the VA is providing the necessary services uniformly 

and across the Nation. 

And, again, Mr. Chairman, I thank you very much for this series 

of hearings. You do a wonderful job as Chairman of this Subcommittee, and I hope to have an informative hearing this morning. Thank you so much. 

Mr. MICHAUD. Thank you very much, Mr. Hare, for your leadership on veterans’ issues as well. 

Our first panel is comprised of Patricia Greer, who is the President of NAADAC, the Association for Addiction Professionals; and 

Dr. Richard McCormick, who is a Senior Scholar from the Center 

for Health Care Policy and Research at Case Western Reserve University in Cleveland, Ohio. 

I would like to welcome both of you here this morning. And look 

forward to hearing your testimony. And we will start with Ms. 

Greer. 

STATEMENTS OF PATRICIA M. GREER, PRESIDENT, NAADAC, 

THE ASSOCIATION FOR ADDICTION PROFESSIONALS; AND 

RICHARD A. MCCORMICK, PH.D., SENIOR SCHOLAR, CENTER 

FOR HEALTH CARE POLICY AND RESEARCH, CASE WESTERN 

RESERVE UNIVERSITY, CLEVELAND, OH 

STATEMENT OF PATRICIA M. GREER 

Ms. GREER. Thank you, Mr. Chairman and Members of this Subcommittee, for holding today’s hearings. 

The multiple challenges to our healthcare system to effectively 

treat co-occurring substance use disorders are significant. But exwwoods2 on PRODPC68 with HEARING

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perience has proven that there are practical steps, which will improve outcomes for clients and their families. 

I represent NAADAC, the Association for Addiction Professionals. We are the national professional association for addictionfocused health professionals and educators. NAADAC has 10,000 

members across the United States and partner organizations in 46 

States, two territories, and several foreign countries. 

I would like to take a minute to note the scope of the problem 

of substance use disorders and comorbidity. In 2004, Dr. Richard 

Suchinsky ranked substance use disorders as third in the list of diagnoses made by the VHA. 

However, reflecting a similar treatment gap in civilian society, 

substance use disorders remain under diagnosed and under treated 

in the VHA. In total, it is estimated that 1.8 million veterans suffered from a diagnosable substance use disorder in 2002 and 2003. 

Substance use disorders often co-occur with other physical and 

mental health conditions. In the case of mental health conditions 

like PTSD, depression, or bipolar disorder, substance use disorders 

may develop from attempts to self-medicate. 

Some experts estimate that about 40 percent of the veterans who 

have served in Iraq or Afghanistan will experience mental health 

problems. And of that number, approximately 60 percent will have 

a substance use disorder. National Guard forces report even higher 

rates of psychological distress than do the regular forces. And the 

stigma against addiction and treatment discourages many people 

from even seeking help. 

The Department of Veterans Affairs and Congress should be 

commended for having made mental healthcare for veterans a priority over the past several years. 

As this hearing’s title suggests, co-occurring addiction and mental disorders are best treated comprehensively. Treatment for substance use disorders is most effective when delivered by trained 

healthcare professionals with either a certification or license in addiction-specific care. Licensure and certification ensures that the 

practitioner has both the education and the clinical experience in 

evidence-based practices to provide the best possible care. 

The commitment by the VHA to prioritize treatment for co-occurring addiction and mental illness must include a commitment to 

expand and train its addictions-focused workforce. Reports that the 

addiction-focused VHA workforce has declined by almost half in the 

past decade are particularly disturbing. 

Simply stated, comprehensive care for co-occurring disorders requires professionals with knowledge of both the areas of addiction 

and mental health trauma. 

Additionally, several steps may be taken to enhance the comprehensiveness of care. 

First, early screening and intervention leads to more successful 

results. Of the veterans in the VHA system with diagnosable substance use disorders, only 19 percent received specialized addiction 

treatment. Primary care health practitioners must be trained in 

identifying substance use disorders and their co-occurring mental 

health conditions. And qualified addiction professionals should be 

on call to provide interventions when needed. 

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Second, we believe that the VA should be accountable and transparent in cases where they do deny treatment to a veteran claiming to have combat-related symptoms or substance use disorders 

and report that information publically. 

Third, culturally competent care reflecting familiarity with military culture is essential for effective treatment. Fourth, the current 

conflicts require a new emphasis on gender-specific treatment 

strategies. Servicewomen are closer to combat than ever before. Female veterans are more vulnerable to PTSD. 

The VHA should invest in studying gender-specific treatment 

and counseling strategies. 

Fifth, with the high rates of Reservists and National Guard 

forces in combat and extended tours of duty, families are under extreme stress. Post-deployment reintegration is often surprisingly 

difficult. Family inclusion in treatment programs are recommended 

whenever possible. 

Sixth, access to treatment should be as convenient and clientfriendly as possible. Compared with the civilian system, both public 

and private, substance use disorder-specific care in the VA takes 

place in hospitals that are densely populated and less geographically dispersed than civilian treatment sites. This problem is particularly pronounced for veterans in rural areas. 

We encourage the Department of Veterans Affairs to aggressively 

pursue partnerships with existing civilian treatment centers. Strategic partnerships that expand the capacity of existing treatment 

systems in underserved areas would provide veterans and their 

families with timely care close to home, which is much more successful. 

In conclusion, the current conflicts in Iraq and Afghanistan pose 

many new challenges requiring a comprehensive plan of action. 

We would like to commend the Department of Veterans Affairs, 

this Subcommittee, and other policymakers who have worked to 

improve veterans’ access to healthcare in the past several years. 

We look forward to working with other stakeholders to improve 

the Nation’s treatment systems for co-occurring substance use disorders. I thank you for the opportunity to testify today. And I 

would also like to acknowledge the addictions treatment professionals in the room who are also veterans with us today. And I 

would be happy to answer any questions. 

[The prepared statement of Ms. Greer appears on p. 43.] 

Mr. MICHAUD. Thank you very much. Dr. McCormick? 

STATEMENT OF RICHARD A. MCCORMICK, PH.D. 

Dr. MCCORMICK. Mr. Chairman, Members of the Subcommittee, 

I will attempt in my limited remarks today to provide an independent, ground-level assessment of the needs of veterans for substance abuse disorder services and the current capability of VA to 

provide them. 

Let me first share the basis for my assessment. I retired a few 

years ago after 32 years in VA, where I worked clinically, mostly 

in substance abuse. Ending my career as the Mental Health Care 

Line Director for Network 10. 

I was Co-chair of the VA National Committee on the Care of Severely Mentally Ill Veterans, the mental health representative to 

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the VA Central Office Task Force overseeing all practice guidelines, 

and Co-chair of the group drafting the practice guidelines for dually diagnosed veterans. 

After I retired, I had the additional opportunity to personally 

visit 39 VA facilities. First as a Commissioner on the VA Cares 

Commission, also as a member of a special Secretary’s mental 

health task force, and then as a consultant on mental health and 

substance issues at a number of facilities. 

The last 2 years, I personally had the opportunity to visit 23 

military bases and Reserve units across the world as a member of 

the Department of Defense (DoD) Mental Health Task Force. 

On these visits, I talked to literally thousands of 

servicemembers, families, and providers about substance abuse and 

mental health issues. 

I continue to conduct National Institute on Alcohol Abuse and Alcoholism funded research at the university and am involved in two 

large Department of Defense follow-up studies on the mental 

health status of National Guard and Reserve members. 

First of all, the scope of the problem. The need for comprehensive 

substance use disorder services is immense and growing. Multiple 

studies show high rates of problems for returning War on Terror 

members. 

For example, among reservists who are veterans, weeks within 

their return, across studies looking at confidential surveys, it 

ranges from the 25 to 35 percent range on average for alcohol problems. When you look at the subset who have frequent deployments 

and high combat exposure, it goes as high as 52 percent. 

This hearing importantly focuses on comorbidities. Substance 

abuse is a common comorbidity for mental and social problems. The 

veteran must be able to access good substance abuse services to 

deal with other conditions as well. For example, most—all PTSD 

programs require that someone either concurrently or before they 

enter PTSD treatment deal with the substance abuse problem, 

which is a common comorbidity for up to one third of those going 

into treatment. 

There is growing concern with suicidality. A recent VA study of 

over 8,000 veterans in substance abuse treatment found that the 

year before they entered treatment, 9 percent had—attempted suicide. The year after, 4 percent. The good news is there was a direct 

relationship to the amount of substance abuse treatment they got 

and the decrease in suicidal behavior. 

What is the—let me just say that VA’s priority medical and mental health programs need a state-of-the-art substance abuse program to provide the care they need to provide. 

What is the state right now? VA has been a leader in establishing evidence-based guidelines for substance use disorders. We 

know what works. In the past decade, VA substance abuse care has 

greatly eroded. Official VA reports document the decline. Much less 

is being spent on the care. Two hundred million dollars less than 

was spent in fiscal year 1996. 

Some of that might be attributed to increased efficiency were it 

not for the fact there has also been a drastic decline in the number 

of unique veterans getting substance abuse care in VA. Nor is this 

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due to lack of need. Three networks actually increased the care 

they provide, while increasing efficiency. 

But the result of this decline across the system, is that there is 

a vast discrepancy in access of a full—to a full continuum of care 

across the country. 

Small improvements can be noted in the past couple of years 

with new money. But even still, there are examples of medical centers that take expansion money for one thing and continue to reduce substance abuse services. 

There are many dedicated staff who provide care. Most VA programs do focus on the more severe, dependent abusers. But the 

new veteran often needs a new kind of service. He or she may be 

at the beginning of a long drop, binge drinking, getting caught 

driving under the influence (DUI), getting DUIs, starting to destroy 

family relationships. 

In the private sector, you will find examples, many examples, of 

comprehensive brief intervention initial treatment programs for 

such patients. 

Alarmingly, these are rare in VA. There are certainly examples 

of bright spots where it is happening. But across the system, they 

just aren’t there. 

I could go on providing more details. But let me end with a true 

story. On a visit to a Reserve unit last year, I was approached by 

a reservist home from his second deployment. He was changed. He 

knew it. His sergeant knew it. His wife knew it. He was drinking 

too much. He wasn’t the father or husband he always saw himself 

being. He had had a tough time in deployment, but he didn’t want 

to talk about that. And he was reluctant even to go get some help 

with his alcohol problem. 

But he did want to do something. I directed him to the nearest 

VA facility nearest where he lived. It was not one I had visited recently. I hope he found ready, immediate access to services that he 

needed, before he talked himself out of sticking with it. Then and 

now, I am not sure he would. 

[The prepared statement of Mr. McCormick appears on p. 47.] 

Mr. MICHAUD. Thank you very much, Dr. McCormick. 

As you know, one of the issues that is important to me is access 

to veterans’ healthcare for our veterans, all over the United States, 

but particularly in rural areas. 

What, Dr. McCormick, are some of the challenges in providing 

substance abuse treatment in rural areas? We heard Ms. Greer 

mention partnerships are one opportunity. Could you talk about 

the effectiveness of telephonic—or Internet-based treatment for 

substance use disorders? 

Dr. MCCORMICK. Yes, thank you. One of the great strengths of 

VA, as you know, I am sure Mr. Chairman, is the establishment 

of community-based outpatient clinics (CBOCs), which are much 

more accessible, including especially to rural veterans than our 

medical centers generally. 

It is appropriate to have the most intensive substance abuse 

services at a medical center to a degree. But at every CBOC, every 

community-based outpatient clinic, in primary care, there needs to 

be someone who is expert in providing brief interventions to try to 

immediately impact, especially on those who are misusing rather 

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than fully dependent, before they spend years going down that 

deep drop. 

And that isn’t true right now. Even 4 years after people are coming back—and they need the services right when they come back 

to stop the drop. And that is true in rural. My own view is that 

the only way we will ever really attack the rural issue completely 

is for VA to contract some of that care in local communities. 

I myself believe VA can still be the provider of care and payer 

for care. But especially if it is an intensive outpatient program or 

even frequent outpatient visits, the reality is that if a veteran—I 

hear this many times. If a veteran has to drive 100 miles both 

ways, with the price of gas today, that is not free care. That is real 

expensive care. It is true in Ohio. I am sure it is true in other rural 

areas, Florida as well. 

So that, yes, I think VA needs to bolster its programs, its intensive programs at the medical center. Make sure every CBOC can 

really provide immediate care. And I will say that there was a survey done. I was part of the group in 2004, VA’s Health Services Research and Development Service (HSR&D) study, a survey of the 

leaders of primary care and ambulatory care in VA. The number 

one barrier they saw through their veterans—and they thought 29 

percent of them had alcohol problems. The number one problem 

they had getting them to have short, brief treatment, was lack of 

resources. 

So VA can direct the care, pay for the care, but they will have 

to contract in some areas to make it truly accessible and useful. 

Mr. MICHAUD. What about Internet-based treatment? Do you 

think that is effective? 

Dr. MCCORMICK. In terms of—you know, I really feel that the 

jury is out whether it is better to treat the disorders at the same 

treatment site or in separate treatment programs. 

But I would stress that the most important thing is that good 

care for mental health conditions and for medical conditions—take 

for example hepatitis C, you can’t really—the effective treatments 

for hepatitis C requires someone—the need to be alcohol free. Likewise, even TBI, traumatic brain injury, one of the cardinal symptoms is disinhibition, often misuse of alcohol. 

And in fact, the current DoD advice for TBI patients is to abstain 

from alcohol. If somebody has TBI and has an alcohol problem, 

they need to be able to get those services. 

I myself think the jury is out whether they have to be done at 

the same time. We are still at the point of trying to make sure that 

every place we should have it, we have a robust, full continuum of 

care. So at least it can be offered concurrently. 

Mr. MICHAUD. Ms. Greer, would you want to answer that question about Internet-based treatment? 

Ms. GREER. My concern on Internet-based treatment is that one 

of the hallmarks of addiction is disconnection from your family, 

your friends, and your support network, your natural support network. So I find it difficult to endorse internet-based treatment for 

addiction disorders. 

Mr. MICHAUD. Ms. Greer you recommend that the VHA should 

provide resources to its current healthcare workforce to become certified or licensed in addiction-specific treatment. 

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How many VA health professionals are currently certified or licensed? What is the process you have to go through? 

Ms. GREER. Well, actually it varies from State to State at this 

point. All the armed services actually have a process, I believe, for 

certifying people that are interested in being certified addictions 

professionals. But it is not consistent nationally. 

Mr. MICHAUD. And with, mental health treatment, involvement 

of the family members is—I feel is extremely important. How do 

you both, Ms. Greer and Dr. McCormick, envision what that family 

involvement should look like? Do you feel that the VA currently 

promotes family involvement in substance use disorder treatment 

for our veterans? 

Dr. MCCORMICK. Let me try that first. That is an excellent question. The reality is that there is less involvement of family actively 

in VA substance abuse programs than any comparable programs 

elsewhere in the community. 

Partly this is regulatory or at least staff belief about regulations. 

The reality is, especially for the new War on Terror veteran coming 

back, when you talk to National Guardsmen when survey—when 

we do surveys of them, marital problems are where things start to 

surface first, especially with repeated deployments. 

And yet, most VA medical centers don’t make marital counseling 

readily accessible. It is available at Vet Centers. But, again, I 

would remind everyone that Vet Centers are much less accessible 

as an entity than our medical centers. And Vet Centers don’t really 

do substance abuse care. So you are talking about trying to separate two things that should be separated, because the family, the 

wife—we are losing families. 

And because of losing families, we are losing veterans and 

servicemembers, including to suicide. It is the number one factor. 

You take these three things together: family problems, or relationship problems, or a ‘‘dear John’’ e-mail, alcohol and access to a 

weapon. That is what you see happening. That is why you see suicide. And that is why you see it so much. 

Mr. MICHAUD. Ms. Greer, do you want to add anything to that? 

Ms. GREER. I think that informing family members of the role 

that they play in post-deployment reintegration would be a key 

step in helping the adjustment to coming home, especially with 

marital difficulties. 

My concern is that speaking to professionals in Fort Hood, I understand their caseloads are in excess of 300, just with returning 

veterans themselves. And they are not able to handle the family 

connections that would go with treating the people they serve. 

So I don’t know how it is nationally. But I know the local providers in Fort Hood are overwhelmed. 

Mr. MICHAUD. Thank you. And my last question, Dr. McCormick, 

since you formerly worked at the VA, we can provide all the resources that we think is needed in this particular area. But my 

concern is once that we do that, is to make sure that the resources 

get to the veterans that need it. 

I guess my question is how do you see that we as a Committee 

can make sure that the resources get where they are needed? What 

type of oversight do you think we need? Is there any report language that we should require the VA to report back? 

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And the other issue is if we do not—if the veteran does not get 

the services that they need, what is that actual cost of that—to society as a whole? How much more expensive would it be since they 

are not getting the services that they need? 

Dr. MCCORMICK. Two very important questions. Let me take the 

first one. You know, when I first came to VA, it was described to 

me as a series of fiefdoms. It changed somewhat, but not a lot. 

On the other hand, one of the things that has happened that is 

very good in VA, is the establishment of practice guidelines. Now 

the substance abuse guidelines need to be expanded with modern 

services on misuse for new veterans. Once that is done, my own belief is that a report card needs to be done on each and every medical center, comparing each and every medical center as to which 

parts of the continuum of care in VA’s own evidence practice guidelines are readily available and accessible at that site. 

That report card should be used for two things. It ought to be 

made public, because frankly there are VA administrators at the 

local level who are recalcitrant about substance abuse services. But 

the light of day of a report like that gets converts that—and nothing else would get. 

Number two, it allows the money that you do give to go to the 

right places, because the bottom line is—as the Member correctly 

said earlier, the bottom line is to try to get accessible services 

across the whole system. So that if a veteran living in Ohio, who 

has a problem, gets the same access as one who lives in Florida. 

And the one in Ohio is probably depressed, because all the defeats 

we have had from Florida teams lately but beyond that. 

The second question you asked is also, you know, important— 

very important as well. And that has—but you have to remind me 

of it, because I am an old man. 

Mr. MICHAUD. Well, first of all, you mentioned having that report 

card. 

Dr. MCCORMICK. Right. 

Mr. MICHAUD. Would you be willing to help to put together what 

that report card should look like? I think all too often what happens is once we pass legislation and it becomes law, that is it. 

There is really not much follow up. 

So I would like to make sure that, number one, that we have a 

report card that is legitimate and would really help us. And second, 

we can evaluate exactly what the Veterans Integrated Services 

Networks (VISNs) and VA are doing. So would you be able to help 

with the Committee staff? 

Dr. MCCORMICK. Yeah. And there are many old VA people like 

myself who are around to do that. I would be glad to. 

I am still trying to remember the second important question. 

Mr. MICHAUD. The second question is when you look at taking 

care of our substance abuse, that has a cost to it. 

Dr. MCCORMICK. Thank you. 

Mr. MICHAUD. But if we do not put that money up front, then 

there are other social costs that could be more expensive, including, 

unfortunately, loss of life because of suicide. 

Dr. MCCORMICK. Well, yes. So first of all, there is—there are social costs, obviously, to the family and to the veteran himself. 

There are also medical costs, because untreated—substance abuse 

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treatment does work, although it is a chronic condition. And the 

earlier we intervene, the more likely we are to be successful down 

the road. 

The good news is the early interventions are our least expensive. 

So they save not only the veteran and his family all the psychological and social pain, they actually save money over time if we 

do them well. 

When substance abuse gets to be chronic, as somebody mentioned earlier, you get all kinds of things, including homelessness. 

Actually the number of patients in our homeless programs is more 

than 70 percent that have a substance abuse problem. 

And also there is a medical cost. Again, as I said earlier, and I 

just used two examples, I am on—we are doing a very large study 

on hepatitis C. If you aren’t able to address substance abuse, it 

does really make it impossible to provide some state-of-the-art medical treatments, because alcohol—excessive use of alcohol really 

keeps you from taking antivirals and many of the drugs that are 

most effective for that. So there is also a medical cost over time. 

Mr. MICHAUD. Thank you. Ms. Greer, did you want to add anything? 

Ms. GREER. I just wanted to add, that the Federal Government 

has studied this issue. I think it was around year 2000, and it indicated that for every dollar we spend on intervention, prevention, 

early treatment, we save $7 down the road avoiding incarceration, 

the chronic deterioration by a chronic disease, and all the related 

societal costs. 

Mr. MICHAUD. That is a very good point. It would probably be 

worthwhile to get an up-to-date cost, since that is 8 years old. 

Ms. GREER. Well, I am sure they could help us? 

Mr. MICHAUD. Yes. Thank you. Mr. Hare? 

Mr. HARE. Thank you, Mr. Chairman. Ms. Greer, from your experience, is the treatment offered for SUD or addictions at the VA 

similar as far as programmatic aspects to those of the public sector? 

Ms. GREER. Unfortunately, I can’t address that question. I 

haven’t worked within the VA system. I only have secondhand reports. 

Mr. HARE. Okay. Dr. McCormick, would you? 

Dr. MCCORMICK. They are for—if we are talking about programs 

for fully dependent patients, they are actually quite similar. The 

basis of them is really an intensive outpatient program with a residential option. 

A couple of things are different. There are few—there is less 

availability for methadone maintenance, which is actually—has a 

very heavy evidence base in VA than it is in the private sector. I 

also do consulting in the private sector. 

And the other one that I would, again, underscore, the—one of 

the huge differences that perhaps is most pertinent to the War on 

Terror is that VA programs are much less likely, in my personal 

experience, to offer early, short, brief interventions for people who 

are just starting down the slope. 

Our programs in VA tend, because of the kinds of patients we 

have treated over the years, to be kind of the end-of-the-line programs. Now when I go around the Nation and you talk to VA subwwoods2 on PRODPC68 with HEARING

11 

stance abuse people, they recognize this. They would like to provide 

short, brief interventions. They just don’t have the time. They are 

already barely floating. 

Mr. HARE. Well, Doctor, let me—you know, I know you worked 

in the VA system, as you mentioned, for several years and traveled 

all over the country. And let me first of all thank you for your service. It is a wonderful thing to do. But can you tell—maybe tell me 

how much of an understanding do you think the VHA professionals 

have about SUD? There seems to be a lot of stigma surrounding 

SUD and whether it is, you know, the willpower to stop, rather 

than a medical condition. 

And I guess my other part to that question is do you find this 

a problem in the VHA facilities? And would you agree with Ms. 

Greer’s assessment that more specialized training for SUD need to 

be integrated into the VHA? It is a long question. I apologize. 

Dr. MCCORMICK. No. Let me start. When you start at the ground 

up, if you talk to primary care doctors, having people come in for 

a 15, 20, most 30-minute visit, and as I said before, their own people say 29 percent of them have an alcohol problem. They recognize 

it is a problem. They recognize they have neither the time nor the 

training to address it. 

So they have to rely on the availability of other resources, particularly in the specialized substance abuse programs, which often 

are not really accessible for them or don’t offer the kind of services 

their patients needed. 

As you go up the line, there are certainly many very enlightened 

VA clinicians and VA managers regarding the importance of substance abuse treatment. But there are many who are not. And this 

is one of the reasons that you have the undeniable variation. I 

mean, there is an order of three variation on the number of—the 

percentage of patients treated completely who get substance abuse 

care in the VA by network. 

So there is no question that that is a reality that, again, has to 

be overcome through top-down enforcement of a consistent continuum of care across the system. 

Mr. HARE. And lastly, I don’t want to run out of time here, Mr. 

Chairman, but I just want to ask Ms. Greer one question. Just to 

clarify what the difference is, if any, between substance abuse disorder and an addiction? 

Ms. GREER. An addiction? 

Mr. HARE. Mm-hmm. 

Ms. GREER. You can have a substance abuse disorder that progresses to addiction. You may just have somebody that is in a 

phase of abusing substances. And that would be a substance abuse 

disorder. And that would be a warning that there is potential for 

dependency or addiction. 

Mr. HARE. I thank you very much. Thank you, Mr. Chairman. 

Mr. MICHAUD. Thank you. Ms. Berkley. 

Ms. BERKLEY. I thank you, Mr. Chairman. And thank you for 

holding this very important hearing. 

I would like to be able to submit my opening statement for the 

record, if I may. 

Mr. MICHAUD. Without objection. 

Ms. BERKLEY. Thank you. 

wwoods2 on PRODPC68 with HEARING

12 

[The prepared statement of Congresswoman Berkley appears on 

p. 42.] 

Ms. BERKLEY. Thank you. Thank you both for being here to discuss with us a very important issue and to help educate us. And 

we always appreciate that. 

A constituent of mine, Lance Corporal Justin Bailey, returned 

from Iraq with PTSD. He developed a substance abuse disorder. 

And I know that they go hand in hand. He checked himself—with 

his family’s insistence, checked himself into the LA VA facility in 

West Los Angeles. After being given five medications on a selfmedication policy, Justin Bailey overdosed and died. His family, obviously, are beside themselves. And can’t understand how he went 

in with a substance abuse problem, and was given more medication 

unsupervised. 

I have introduced the ‘‘Mental Health Improvements Act,’’ which 

aims to improve the treatment and services provided by the Department of Veterans Affairs to veterans with PTSD and substance 

abuse disorders. 

And what the legislation does is it expands substance abuse disorder treatment services at VA medical centers. It establishes national centers of excellence on PTSD and substance abuse disorders. It creates a program for enhanced treatment of substance 

use disorder and PTSD in veterans. It requires a report on residential mental healthcare facilities in the VA, creates a research program on comorbid PTSD and substance abuse disorders, and it expands assistance of mental health services for families of veterans. 

I think it is imperative that we provide adequate mental health 

services for those who have sacrificed for this Nation and those 

who continue to serve. Oftentimes these problems don’t manifest 

themselves until quite a while after the service. But it is a serious 

issue. And we are recognizing it now, where I think in past wars, 

it existed. And we just chose not to recognize it. 

I am hoping that my colleagues, and I know there are only two 

here, will help cosponsor this and move it along. I think it is important and will help. 

But, Ms. Greer, I wanted to ask you. I am not sure. I mean, we 

are putting a lot of burden on our VA. In addition to the healthcare 

that our veterans require when they come home, and we will have 

several hundred thousand if not close to a million veterans from 

the current action and our resources are scarce. Added to the 

healthcare issues are also the mental health issues. 

And I am not sure—as a matter of fact I am quite convinced that 

we don’t have enough people—doctors in the VA to accommodate 

the—what we are tasking them with, and will continue to task 

them with, and expand their task. 

Ms. Greer, do you think it would be beneficial to allow civilians 

to provide care to veterans with substance abuse disorders if they 

are qualified addiction specialists? Because right now our military 

people have to go through the VA. 

If we don’t have enough personnel, and enough doctors, and 

enough addiction specialists to handle the influx of people that 

need their services, do you think it would be appropriate to reach 

out or go beyond the VA and certify addiction specialists that are 

not in the VA system to help treat these people? 

wwoods2 on PRODPC68 with HEARING

13 

Ms. GREER. Well, absolutely. The establishment of professional 

standards is part of what our association does. So I can wholeheartedly recommend using certified addiction professionals or licensed addiction professionals, because they have got the training 

and the specific ability to be meaningful in their interventions with 

clients. 

Ms. BERKLEY. Thank you very much. 

Mr. MICHAUD. Thank you. Mr. Salazar? Well once again, Ms. 

Greer and Dr. McCormick, I want to thank you very much for your 

enlightening testimony. I appreciate you coming here today. 

Dr. MCCORMICK. Thank you. 

Ms. GREER. Thank you, Mr. Chairman. 

Mr. MICHAUD. I now ask the second panel to come forward. Joy 

Ilem who represents the Disabled American Veterans (DAV); Doctor Thomas Berger who represents the Vietnam Veterans of America (VVA); and Todd Bowers who represents the Iraq and Afghanistan Veterans of America (IAVA). 

And I would like to thank the three of you for coming forward 

today to give your testimonies. And I would start off with Ms. Ilem. 

STATEMENTS OF JOY J. ILEM, ASSISTANT NATIONAL LEGISLATIVE DIRECTOR, DISABLED AMERICAN VETERANS; THOMAS 

J. BERGER, PH.D., CHAIR, NATIONAL PTSD AND SUBSTANCE 

ABUSE COMMITTEE, VIETNAM VETERANS OF AMERICA; AND 

TODD BOWERS, DIRECTOR OF GOVERNMENT AFFAIRS, IRAQ 

AND AFGHANISTAN VETERANS OF AMERICA 

STATEMENT OF JOY J. ILEM 

Ms. ILEM. Thank you, Mr. Chairman and Members of the Subcommittee. 

Thank you for inviting the Disabled American Veterans to testify 

at this important hearing on substance use and co-existing mental 

health disorders in the veteran population. 

We owe our Nation’s disabled veterans access to timely and appropriate care, including specialized treatment programs for those 

suffering with post-deployment mental health and substance use 

disorders. 

DAV has a growing concern about the reported psychological effects of combat deployments on veterans who have served in Iraq 

and Afghanistan. There is converging evidence that substance use 

among other post-deployment mental health problems is a significant problem challenge for many of these veterans. And that the 

incidence of this problem will likely continue to rise if not properly 

addressed. 

At one facility, VA researchers examined substance abuse and 

mental health problems in returning Iraq veterans and concluded 

that increasing attention is being paid to combat stress disorders 

but that there was insufficient systemic focus on the substance 

abuse problems in this population. 

Access to substance abuse services for the group studied was 

very low, only 9 percent, compared with access to other mental 

health services, reported at 41 percent. 

In my written statement, I also cite a number of other studies 

that illustrate the apparent nature and scope of this problem. 

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14 

Unfortunately, over the past decade, VA substance abuse rehabilitation services have declined and VA has made little progress 

in restoring them, even in the face of higher demand from the newest generation of combat veterans. 

Although it is well known that many mental health conditions, 

including PTSD, anxiety disorders and depression are frequently 

associated with substance misuse, VA is not sufficiently focused on 

restoring these specialized services, including integrated treatment 

programs to address these co-existing disorders. 

We are also concerned about the market increase in geographic 

variability of access to comprehensive substance abuse services 

noted across the VA system, as well as reported inconsistencies in 

offering inpatient detoxification services. 

We hope VA will set in place clear policies to ensure that a comprehensive set of substance abuse disorder services are available 

and consistently provided to all veterans who need them. These 

services should include screening in all care locations, particularly 

in primary care; short-term outpatient counseling, including motivational intervention; ongoing aftercare and outpatient counseling; 

intensive outpatient treatment; residential care for the most severely addicted; detoxification and stabilization services; ongoing 

aftercare and relapse prevention; self-help groups; and, opiate substitution therapy and other pharmacological treatments, including 

access to newer drugs to reduce cravings. 

While we applaud VA’s efforts to save individuals from the misery of chronic addiction, we note that VA has traditionally limited 

its program focus on those who have seemingly hit rock bottom. 

Experts agree that early interventions for substance use are more 

successful when they have not been allowed to become compounded 

or chronic. 

Therefore, we believe access to a robust array of substance abuse 

disorder services and an expanded focus on prevention and early 

intervention is not only warranted, but critical to our newest generation of war veterans suffering with post-deployment readjustment issues. 

Lack of access to such services could result in sub-optimal rehabilitation for thousands of veterans, including many with comorbid 

medical and mental health conditions that require concurrent retreatment of their alcohol and/or substance use disorders. 

With these views in mind, DAV recommends the Subcommittee 

advance legislation that assures a full continuum of substance use 

disorders care for veterans who need it, along with an annual update to Congress on VA’s progress in providing such services. 

We also urge authorization of a pilot program, specifically designed to offer web-based options for VA substance use counseling, 

treatment, and group support targeted at rural veterans. 

And finally designated funding for research projects to identify 

best treatment strategies to collectively address substance use disorders and other comorbid mental health readjustment problems. 

Congress and VA must ensure that Federal programs aimed at 

meeting the unique post-deployment needs of veterans are sufficiently funded and adapted to meet them, while continuing to address the chronic health maintenance needs of previous generations 

of disabled veterans. 

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Additionally, Congress should require VA to report on how it is 

spending the significant new funds that have been added and earmarked for the purpose of meeting post-deployment mental 

healthcare and physical rehabilitation needs of Operation Iraqi 

Freedom/Operation Enduring Freedom (OIF/OEF) veterans. 

In closing, VA needs to have effective programs in place now 

aimed at prevention and early intervention, outreach and education, as well as training for veterans and their families to close 

the current gaps that exist. 

We deeply appreciate the Subcommittee’s interest in these 

issues. And we want to thank the Chairman and Ranking Member 

for jointly introducing the ‘‘Veterans Substance Use Disorders Prevention and Treatment Act of 2008,’’ a measure that would accomplish many of the goals that we have mentioned today. 

Mr. Chairman, that concludes my statement. Thank you. 

[The prepared statement of Ms. Ilem appears on p. 50.] 

Mr. MICHAUD. Thank you. Doctor. 

STATEMENT OF THOMAS J. BERGER, PH.D. 

Dr. BERGER. Vietnam Veterans of America thanks you for the opportunity to present our views on substance abuse and comorbid 

disorders. 

As you are well aware, substance abuse and PTSD form one of 

the pillars for my organization. And after 30 years in existence, 

still represent a very important component of our legislative agenda. 

Foremost VVA thanks you for your leadership in holding this 

hearing today on a most serious concern within the veterans’ community, because each month hundreds of active-duty troops, Reservists and National Guard members return to their families and 

communities from deployment in Iraq and Afghanistan. 

Given the demanding and traumatizing environments of their 

combat experiences, many veterans experience psychological 

stresses that are further complicated by substance use and related 

disorders. In fact, research studies, as we have already heard this 

morning, indicate that veterans in the general U.S. population are 

at increased risk of suicide. 

I was greatly heartened to hear the Chairman refer to the National Survey on Drug Use and Health Reports. I am not going to 

spend any time going over those figures, since they have already 

been mentioned. 

But we must remember that those data that the Chairman presented to us today, only those veterans who chose to seek help for 

their disorders from the VA are the ones that are mentioned. 

VVA has no reason to believe that the numbers cited in that report would not be higher if more of our OEF and OIF veterans 

were to seek VA care. 

I should also like to point out that yesterday an article appeared 

in the ‘‘Stars and Stripes,’’ just briefly. It was the results of the Defense Department’s health behavior survey, which indicated 

amongst young sailors, airmen, especially Marines and soldiers, 

18.5 percent overall indicated on the questionnaire that they would 

be put in the category of heavy drinking. The Army’s actual rate 

wwoods2 on PRODPC68 with HEARING

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was higher, 24.5 percent. So the numbers we heard mentioned by 

the Chairman earlier, I submit, may be actually higher. 

The medical, social, and psychological toll from substance abuse 

disorders is enormous, both for the military and the civilian sectors. In the face of such overwhelming damage, two questions come 

to my mind: Why does substance abuse receive relatively little 

medical and public health attention and support compared with 

other medical conditions? And what can be done to reduce the 

harm from substance abuse disorders? 

Despite their huge toll, substance abuse disorders remain underappreciated and underfunded. And reasons for this include, in my 

opinion, stigma, tolerance of personal choices, acceptance of youthful experimentation, pessimism about treatment efficacy, fragmented and weak leadership, powerful tobacco and alcohol industries, underinvestment in research, and difficult patients. 

Now I am not going to spend a lot of time going over all of those, 

but despite those obstacles, VVA believes that a coordinated, workable agenda within both the military and civilian sectors is possible 

to lessen the impact of substance use disorders. 

But this better approaches for treatment. For example, adequate 

treatment for substance abuse is particularly challenging for America’s uninsured. Even for the insured, many policies, including most 

Medicaid programs, do not cover the time for counseling or the 

costs of drugs for substance use disorders. Again, as new, effective 

drugs come on the market, patients must have access to them. 

We need to devote more support for research. Increase the percentage of the current National Institutes of Health (NIH) budget 

to substance abuse research. For example, beyond studying the 

basic science of addiction and exploring new pharmacologic treatments, research could help us better understand why some people 

who experiment with substances become addicted while others do 

not. 

There needs to be better education of health professionals. Substance abuse receives minimal notice in undergraduate and graduate medical school curricula, especially board certifying exams, 

continuing medical school education, standard clinical textbooks, 

and medical journals. 

There needs to be stronger leadership. Greater recognition of 

substance abuse and substance abuse disorders as a major health 

program or problem should encourage broader and more diverse 

leadership. 

We also need to provide adequate treatment for communitybased and incarcerated people with drug addiction, because it generates social and medical savings, lower crime, lower prison spending, less family dysfunction, and better health. 

A RAND report of mandatory minimum sentences for cocaine 

concluded that dollar for dollar, treatment is fifteen times more effective than incarceration in reducing serious crime. 

We also need to reform the criminal justice system for substance 

abuse. Federal and State legislation imposes mandatory terms for 

possession of illicit drugs, thereby removing sentencing discretion 

from the hands of judges. Drug courts are an effective antidote to 

this. 

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Substance abuse remains a serious medical, public health, and 

social problem in both our civilian and military sectors. Yet it lacks 

champions, is underfunded, and is relatively neglected by clinicians 

and the medical establishment. 

Despite some real progress in the past decade, the United States 

still lags behind virtually every developed country in measures of 

health status. Our current national strategy to close that gap involves funding for biomedical research to yield new treatments and 

improving access to care for everyone, including America’s veterans. 

That concludes my testimony. Thank you very much. 

[The prepared statement of Dr. Berger appears on p. 54.] 

Mr. MICHAUD. Thank you, Doctor. Mr. Bowers? 

STATEMENT OF TODD BOWERS 

Mr. BOWERS. Mr. Chairman, Ranking Member, and distinguished 

Members of the Subcommittee, on behalf of the Iraq and Afghanistan Veterans of America, and our tens of thousands of members 

nationwide, I thank you for the opportunity to testify this morning 

regarding veterans’ substance abuse. 

I would like to make it very clear also that I am here testifying 

in my civilian capacity as the Director of Government Affairs and 

my opinions and views today in no way reflect the Marine Corps, 

which I currently serve as a sergeant in the Reserves. 

I would like thank the Committee for recognizing the issue of comorbidity. As the Committee knows, among the hundreds of thousands of troops returning from Iraq and Afghanistan with a mental 

health injury, a small but significant percentage is turning to alcohol and drugs in an effort to self-medicate. Veterans’ substance 

abuse problems, therefore, cannot and should not be viewed distinct from mental health problems. 

According to the VA Special Committee on post traumatic stress 

disorder, at least 30 to 40 percent of Iraq veterans, or about half 

a million people, will face a serious psychological injury, including 

depression, anxiety, or PTSD. Data from the military’s own Mental 

Health Advisory Team shows that multiple tours and inadequate 

time at home between deployments increase rates of combat stress 

by approximately 50 percent. 

We are already seeing the impact of these untreated mental 

health problems. Between 2005 and 2006, the Army saw an almost 

threefold increase in ‘‘alcohol-related incidents,’’ according to the 

DoD Task Force on Mental Health. 

The VA has reported diagnosing more than 48,000 Iraq and Afghanistan veterans with a drug abuse problem. That is 16 percent 

of all Iraq and Afghanistan veteran patients at the VA. These numbers are only the tip of the iceberg. Many veterans do not turn to 

the VA for help coping with substance abuse, instead relying on 

private programs or avoiding treatment altogether. 

Effective diagnosis and treatment of substance abuse is a key 

component of IAVA’s 2008 legislative agenda. First and foremost, 

IAVA supports mandatory and confidential mental health screening by a mental health professional for all troops, both before and 

at least 90 days after a combat tour. Moreover, the VA must be authorized to bolster their mental health workforce in hospitals, clinwwoods2 on PRODPC68 with HEARING

18 

ics, and Vet Centers with adequate psychiatrists, psychologists and 

social workers to meet the demands of returning Iraq and Afghanistan veterans. 

At this point, I am going to separate from my written testimony 

and try and share with the Committee an experience I had a week 

before last at my Marine Corps Reserve Center. We all have heard 

about the post-deployment health reassessment (PDHRA) survey. 

This is a form that individuals are required to fill out when they 

return. We filled this out the weekend before last. And I wanted 

to highlight a few of the questions that are actually on here. 

On section 10, question A and B, we have, ‘‘In the past month, 

did you use alcohol more than you meant to? Yes or no. In the past 

month, have you felt that you wanted to or needed to cut down on 

your drinking? Yes or no.’’ And at the bottom there is still an element of self diagnosis for whether you would like follow-up treatment, which is, ‘‘Are you currently interested in receiving information or assistance for a stress, emotional or alcohol concern?’’ 

Now I have to say that filling this form out was incredibly useful 

for our Reserve Center. It allowed people to fill this out confidentially and then sit down with a counselor that would review the 

PDHRA and recommend whether individuals needed to go see a 

mental health professional or a follow-up appointment. 

The important aspect of this was that we were allowed a confidential referral notice. When we filled out the paperwork, if we 

did want a follow-up appointment, it was kept completely confidential. From that point, we moved over and the Veterans Administration was at our Reserve Center to enroll every single person who 

had just completed the PDHRA or who had deployed for over a 90- 

day period with the Veterans Administration. They provided us a 

tremendous amount of pamphlets. I have four here approximately, 

each stating that they have resources available for substance abuse 

problems. 

At that point we then contact—we were connected with our local 

Vet Center. We spoke with individuals from Maryland, Washington, DC, and Virginia, because we are stationed here in Washington. And they put us in touch with the right sources. 

To sum it up, it was perfect. It is exactly what needs to be done 

for a seamless transition for individuals in the National Guard, Reserves, and also active duty to transition to the VA. 

The problem was, it was one corpsman at my unit who organized 

this. It is not mandated across the board for individuals to have the 

same sort of screening process and information sessions on what 

resources are available and, more importantly, communication for 

these individuals. It was just our unit being proactive. 

So I would like, if anything is taken away from my testimony 

today, that we see that there needs to be that communication of resources directly with the National Guard units and Reserve units 

for Iraq and Afghanistan veterans to know what resources are 

made available. 

I have been home from my last deployment to Iraq for almost 3 

years now. And we are just now getting it right. They are just now 

doing it. But it is not across the board. If we do the same type of 

screening that we have done for my unit, for every Reserve Center, 

again, we can keep people from falling through the cracks. 

wwoods2 on PRODPC68 with HEARING

19 

And I welcome any questions at this point. Thank you. 

[The prepared statement of Mr. Bowers appears on p. 58.] 

Mr. MICHAUD. Thank you very much, Mr. Bowers. That was very 

enlightening. And I really appreciate it, because actually that is 

where a lot of my questions were going. 

As with any behavioral conditions, early interventions for substance abuse disorders, effective screening is extremely important. 

I guess I would ask the other two how—you heard Mr. Bowers 

mention what he thought was very helpful. How would you assess 

the VA’s substance abuse screening protocol, and what suggestions 

would you have about the VA and the DoD? How can they work 

together to provide outreach for returning veterans for OEF and 

OIF or veterans in general? 

Dr. BERGER. Mr. Chairman, I will just jump in right here. I think 

what Mr. Bowers said is very, very appropriate. But as he said, it 

took him 3 years to get to this point. So what can we do to make 

sure that it permeates the system for our returning vets? 

Mr. MICHAUD. Is there anything that Mr. Bowers did not say or 

any additional ways that the VA or DoD might be able to further 

this along? 

Dr. BERGER. I would just like to note that I was a Navy corpsman. And I have served as a Navy corpsman with the Marines in 

Vietnam. 

Mr. MICHAUD. Great. Ms. Ilem, do you have any—— 

Ms. ILEM. I think you mentioned at the opening of the hearing 

about VA indicating that they are—they have sent out memorandum or whatever making sure that substance abuse services 

are available throughout—comprehensive services throughout the 

system. And I think, you know, that will take oversight on their 

behalf to make sure then, really at the local levels, that that is 

happening. 

I know that the Vet Centers have testified before that they have 

been actively going out. And certainly their reports reflect that in 

terms of providing support for these returning troops in the Guard 

and Reserve. 

It would be interesting to, you know, continue to see the number 

of folks that they are really assisting. And if they are, you know, 

taking it—doing this type of a program. And making sure that that 

is consistently available in their Vet Centers throughout the country. 

Mr. MICHAUD. Great. 

Dr. BERGER. Mr. Chairman, if I might add one thing. I participate in the Transitional Assistance Program in the State of Missouri. 

The brochures and handouts that Mr. Bowers mentioned, that 

would be appropriate to hand out at these kinds of meetings. And 

I know that our returning troops get exposed to a lot of paperwork 

and a lot of information at these transition assistance program 

meetings. 

But the fact of the matter is, that the materials on substance 

abuse and PTSD need to be bumped up toward the top of the list, 

because that is what is affecting these folks. 

Mr. MICHAUD. Mr. Bowers, do you have anything else you want 

to add to that? 

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Mr. BOWERS. Just real quickly if I could, Mr. Chairman. One of 

the things that we have highlighted is that the Vet Centers, though 

they are an outstanding resource, are extremely understaffed right 

now. And that is something that when I spoke to individuals at the 

Vet Centers, they said we are just—we are getting beat up right 

now. And they do need some help in staffing shortages. 

Mr. MICHAUD. Thank you. Doctor, you had mentioned research at 

NIH, and research is very important. Are there any specific areas 

of research or research questions relating to substance abuse or comorbid disorders that you think the VA should focus on? 

Dr. BERGER. As I hinted at, Mr. Chairman, research questions 

that focus on helping us understand why people who—some people 

who experiment with substance become addicted, while others do 

not. 

The area of resiliency—the comparative efficacy, excuse me, of 

different modes of treatment, because you know there is some conflict in certain circles amongst pharmacological versus psychological treatment or the 12-step program treatments. 

The complexities of dual diagnosis, that is the co-occurring mental illnesses and substance abuse, the social context of addiction, as 

you yourself know from the information you gave us this morning, 

that individuals who are in lower income areas, that is less than 

$20,000 on that national drug survey, seemed to be—are at higher 

risk for substance use disorders. And, obviously, the impact of our 

various social policies on addiction and the harm it causes. 

Those are all questions that could be turned into significant research components in my estimation. 

Mr. MICHAUD. Thank you. My last question is it is my understanding from talking to a veteran last week, a member of the Veterans of Foreign Wars (VFW) of the United States, the Deputy Secretary of the VA and the Surgeon General were talking to the VFW 

and mentioned PTSD–NR. It was the first time I ever heard it, the 

new classification of PTSD–NR. I assume the NR is probably normal reaction. I am not sure. 

Have any of you heard of that new classification? 

Have any of your members brought it forward? And I’ll ask this 

of the VA when they come up, what the NR is for. 

Dr. BERGER. I will just add, I have not heard about that specifically. But one takeaway I did gather from my Marines this weekend was that they said, if there are no problems with it, why is it 

still referred to as a disorder. Everybody kept pushing whether it 

was Army’s Battle Mind training or things along those lines saying 

that, there is nothing wrong with it, but it is still a disorder and 

until that name change comes, until that national stigma is reduced about mental health issues, which whether it be a combat 

mental injury, whatever name people decide to give it, we are going 

to have a really hard time getting folks to step up and get the 

treatment that they need. 

Dr. MCCORMICK. I have not heard of any either, sir. 

Mr. MICHAUD. Okay. Thank you. Ms. Berkley? 

Ms. BERKLEY. Thank you Mr. Chairman. Thank you all very 

much for outstanding presentations. Actually all of our presenters 

have been quite informative. 

Just an observation, I guess, and then a question at the end. 

wwoods2 on PRODPC68 with HEARING

21 

I spend a considerable amount of time with my veterans in the 

Las Vegas Valley in Southern Nevada, and of course we have got 

the fastest growing veterans population in United States there. 

On the 4th of July in addition to other times that I interact with 

my homeless vets, on 4th of July, I go to the United States Vets 

Home for the homeless and get on the buffet line and serve our veterans, and it occurs to me, when I am standing there serving, that 

they are mostly Vietnam Vets, which is my age group and my war, 

for lack of a better word. I was very comfortably serving at the 

University of Nevada when these men, mostly, were in Vietnam. 

It always strikes me when I sit down and talk with my Vietnam 

Vets who are homeless, and have some major issues. What I am 

struck with, is we have normal conversations all the time and they 

are quite intelligent and if not for the grace of God, go I, but I’m 

wondering if we have any statistics that you can share with us on 

the comorbid substance use disorders for Vietnam Vets. Is it particularly prevalent? Is it just that we ignored it at the time? What 

information can you give me? And I know that with each war we 

have our own set of issues with our veterans, many similar, but 

many unique to that particular war. But I know my Vietnam Vets 

had a very, very tough way to go when they came home. And here 

we are many years later and they are, you know, still suffering 

from the experience. 

Dr. BERGER. That is a very good question, ma’am. Amongst my 

generation with everything that was going on at the time. World 

War II and Korea Vets came home and drank a few beers. It was 

a good time. We won. 

Ms. BERKLEY. Yeah. 

Dr. BERGER. Vietnam, there were lots of things going on within 

our culture, and our drug of choice was marijuana for the most 

part. And while we are not proud of that, that is what happened. 

We were also disenfranchised. And I think particularly when 

we’re talking about my cohort of veterans, all these things came together, unfortunately, and that is why you will occasionally run 

into vets, as you said, at these festivals or celebrations from Vietnam. 

Ms. BERKLEY. Do we have any statistics regarding substance 

abuse for our Vietnam Vets? 

Dr. BERGER. I will have to ask my colleagues from the VA. 

Ms. BERKLEY. Okay, just curious about that. And let me ask you, 

I asked the question to Ms. Greer in the earlier panel, do you feel 

in the least bit uncomfortable with having civilians that have specialties in addiction services counsel? 

Dr. BERGER. I have no problem with it on one hand however; as 

I mentioned a couple of weeks ago while testifying on mental 

health related issues, I think it is important when you are talking 

about the use of nonmilitary trained people, that there is an element of trust. 

Ms. BERKLEY. Yes. 

Dr. BERGER. Okay. That has to be overcome and I don’t care 

whether we are talking about mental health professionals or substance abuse professionals. Trust is very important when it comes 

to dealing with our Nation’s military when it comes to these particular disorders we are talking about. 

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So with caveat in mind, no, I do not have a problem with it. 

Ms. BERKLEY. Okay. Anybody else care to comment? 

I am just concerned about the lack of resources in the VA and 

personnel that can treat the numbers of people coming back with 

substance abuse disorders and PTSD. And I know, look my dad is 

a World War II Vet, he would not go anyplace else for his 

healthcare than the VA. I mean, there is a camaraderie, there is 

a comfort level. 

And I know that there are thousands of my World War II Vets 

in Vegas that they could easily go to another place for their 

healthcare, they want to go to the VA. They like going there. They 

like seeing their friends. They like the comfort level there, and I 

don’t think that should be denied. But there ought to be some way 

that we can get civilians that may have served that can relate to 

our returning veterans that have PTSD and substance abuse problems that aren’t necessarily working for the VA. 

Dr. BERGER. I think there are ways particularly to take advantage, as was mentioned a couple of weeks ago before this very Committee, to take advantage of peer counseling programs when it 

comes to substance abuse. I know if that would have been available 

for Vietnam Veterans there would be a lot fewer Vietnam Veterans 

with substance abuse issues today. 

Ms. BERKLEY. Thank you, very much. 

Mr. MICHAUD. Just one last question, doctor. You had mentioned 

incarceration as I said earlier. If you don’t take care of the problem 

up front, we have a long cost, at the other end. 

Dr. BERGER. That’s correct. 

Mr. MICHAUD. Have there ever been any studies done about veterans who might have been incarcerated for alcoholism or drug 

abuse, because that actually shifts the burdens on to the State and 

the county jails and what have you. Do you know if there have ever 

been any studies done on that? 

Dr. BERGER. There have been a couple of studies that many of 

the folks behind the walls do have substance abuse problems. I 

wish I could just find it here in all the information I brought along 

today. I am one of those who tend to bring more ammunition than 

I actually need. 

Mr. MICHAUD. Well, if you could just provide it to the Subcommittee. 

Dr. BERGER. Well it is in my testimony, sir, where I hint at it. 

But it is a problem within the penal system, substance abuse disorders. 

Mr. MICHAUD. Because I do know that also, that is not the only 

cost of keeping someone incarcerated, but also if the county has to 

take up the cost of providing the healthcare, versus the VA, that’s 

an added cost at the State level that really concerns me. 

So I would like to, if there has not been an up-to-date study on 

that, I would be very interested in making sure we get one because 

that is a shift that should not occur. 

Dr. BERGER. Okay. One thing, if I may mention, sir. Vietnam 

Veterans of America is very proud of the fact that we have chapters inside the walls at many of our institutions and no other veterans service organization can make that claim. 

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23 

Mr. MICHAUD. Thank you. Once again I want to thank this panel 

for your testimony this morning and look forward to working with 

you as we move forward with this piece of legislation. I thank each 

of you very much. 

Our last panel is Dr. Antonette Zeiss, who is the Deputy Chief 

Consultant for the Office of Mental Health Services within the 

VHA, accompanied by Charles Flora, the Associate Director of Readjustment Counseling Service, and Dr. John Paul Allen, the Associate Chief Consultant for Addictive Disorders. 

I would like to welcome the doctor, and the other two that are 

accompanying you today and look forward to hearing your testimony as well. 

STATEMENT OF ANTONETTE ZEISS, PH.D., DEPUTY CHIEF 

CONSULTANT, OFFICE OF MENTAL HEALTH SERVICES, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF 

VETERANS AFFAIRS; ACCOMPANIED BY CHARLES M. FLORA, 

ASSOCIATE DIRECTOR, READJUSTMENT COUNSELING SERVICE, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS; AND JOHN PAUL ALLEN, 

PH.D., ASSOCIATE CHIEF CONSULTANT FOR ADDICTIVE DISORDERS, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS 

Dr. ZEISS. Thank you very much for having us here at this very, 

very important hearing. Like the other panelists we share the 

sense that this is really tremendously important, and we’re very 

glad to be able to talk about what the VA is doing and to answer 

your questions. 

I am pleased to be here today to discuss those ongoing steps that 

the VA is taking to treat substance use disorder and comorbid disorders. 

I am accompanied by Mr. Charles Flora who is the Associate Director of Readjustment Counseling Service. He is a clinical social 

worker and Vietnam veteran, and has a lifetime of experience in 

readjustment counseling at both the Vet Center and national levels. 

I am also accompanied by my colleague and my new friend, Dr. 

John Allen, Associate Chief Consultant for Addictive Disorders in 

the Office of Mental Health Services. 

Dr. Allen is a national expert on substance use disorders and he 

is a veteran of Operation Iraqi Freedom. 

The VA has always taken the problem of substance use disorder 

very seriously and has demonstrated our commitment to helping 

our veterans overcome this disease and we welcome Dr. Allen’s personal connection to our returning veterans as well as his expertise 

in this area. 

We thank the Committee and you, Chairman Michaud, for your 

active interest in this topic. Tragically, substance use disorders are 

common in our society, as you have been hearing daily and are 

definitely common as they are in many societies. And the incidence 

of substance use among veterans tends to exceed that of comparable civilian populations. For example one study by Todd Wagner, in 2007, found that veterans are more likely than non-veterans 

to report driving under the influence of alcohol, smoking daily, and 

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using marijuana. In another study, Dr. Charles Hoge published in 

the New England Journal of Medicine in 2004 showing that the 

number of respondents who admitted to using alcohol more than 

they intended, increased 7 percent among Army respondents after 

deployment to Iraq or Afghanistan. 

Alcohol and drug misuse are associated with a host of medical, 

social, mental health, and employment problems. Fortunately, 

those problems are treatable, and with treatment, the lives of our 

patients and their loved ones can be enriched. 

Since the implementation of the Mental Health Strategic Plan in 

VA, which began to be rolled out in 2005, the VHA has dedicated 

more than $458 million to improve the access and quality of care 

for veterans who present with substance use disorder treatment 

needs. 

We have funded 510 new substance use counselors; that’s what 

my written testimony says, I checked this morning and it is actually about 520, and we plan to continue expanding substance use 

disorder services throughout fiscal year and next fiscal year. 

For example, this year, our mental health enhancement budget 

includes over $37.5 million for expanded substance use disorder 

services. 

Whenever a veteran is seen by a VA provider for the first time 

and then at annual retesting afterward, he or she is screened for 

PTSD, military sexual trauma, depression, and problem drinking. 

We recognize screening is only valuable if we act upon positive 

screens and follow-up in a timely manner, and we are committed 

to doing that. 

For those needing additional services when screening and evaluation has occurred our outpatient and inpatient substance use disorder programs are available; there are more than 220 programs 

in place, with more in development. 

We maintain extended care facilities, including 19 inpatient programs designed specifically to treat substance use disorder for 14 

to 28 days. There are 44 residential rehabilitation treatment facilities that focus on substance use, 15 compensated work therapy programs with substance use particular emphasis, and 19 domiciliaries that focus on substance use disorder. 

Mental healthcare, including attention to substance use disorder, 

is being integrated into primary care clinics, and we also are integrating mental health services into our community-based outpatient clinics, nursing homes, and our home-based primary care 

teams. 

Placing mental health providers in the context of primary care 

for the veteran is essential; it recognizes the interrelationships of 

mental and physical health, as well as providing mental healthcare 

at the most convenient and desirable location for the veteran. 

In addition to the care offered in medical facilities and community-based outpatient clinics, VA’s Vet Centers provide outreach 

and readjustment counseling services to returning war veterans of 

all eras. 

It is well-established that rehabilitation for war-related PTSD, 

substance use disorder, and other military-related readjustment 

problems, along with the treatment of the physical wounds of war, 

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is central to VA’s continuum of healthcare programs specific to the 

needs of war veterans. 

The Vet Centers provide an alternative to traditional mental 

healthcare that helps many combat veterans overcome stigma and 

the fear related to accessing professional assistance for military-related problems. 

Substance use disorder is a real problem, and its manifestation 

along with other mental health conditions can lead to physical 

health concerns, difficulty readjusting to civilian life, and a host of 

other problems. 

One of VA’s highest priorities is to reduce the impact of substance abuse and provide veterans with the care they need. 

Thank you for your time and for the opportunity to discuss this 

important issue with you. I would like to turn to addressing any 

questions that you have. 

[The prepared statement of Dr. Zeiss appears on p. 59.] 

Mr. MICHAUD. Thank you very much doctor. You had mentioned 

that you established 520 new substance use counselors. It is also 

my understanding that you downsized a number of years ago, so 

is this just getting you back to where you should be? But I guess 

the more important question is, I don’t necessarily look at the increases or decreases, what I look at when I look at programs is, are 

you taking care of the problem? 

So how many of those 520 are actually onboard and are they taking care of the problem that we currently see out there today and 

do you have enough? 

Dr. ZEISS. Wonderful question and a very complex question. 

First of all let me say, it is absolutely true, there was a period 

in the history of VA’s healthcare when there was a decline in availability of mental health and substance abuse treatment services. 

And the development of the Mental Health Strategic Plan in 2004 

and its implementation beginning in 2005, have just been essential 

and enormously important. And it has been paired with provision 

of strong resources, financial and support resources within VA, as 

well as the financial support we receive from Congress. 

So there has been a huge turnaround in the last couple of years, 

and we know that the mental health staff overall now is well above 

the levels at the historical high earlier which was around 1996 and 

1997. 

We are above the earlier staffing for some components of substance use care, but because we also shifted from a primarily inpatient model of care to residential rehabilitation and intensive outpatient, the overall number of staff in substance use disorders 

would not be higher because there is not that round the clock nursing staff that would have been counted earlier. But in terms of our 

staffing to be able to cover the problem, I think that we are definitely well along the way, and we intend to continue to expand 

staff and to expand those services. 

You probably know that overall in VA in addition to the substance use positions that I have described, we have, in the last 2 

years hired over 3,800 new mental health professionals and support staff. Almost entirely professional staff, but some support 

staff. 

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26 

So its really a very different VA than it was in 2004. And maybe 

with that I can let you say a bit, Dr. Allen, about some of the 

changes. 

Mr. MICHAUD. Are all 520 hired? 

Dr. ZEISS. Over 90 percent are. 

Mr. MICHAUD. Over 90 percent. 

Dr. ZEISS. There’s about 50 still in the works. 

Mr. MICHAUD. Okay. 

Dr. ZEISS. They are in the pipeline. They are coming along to be 

hired. 

Mr. MICHAUD. If Dr. Allen could address this also, we heard Mr. 

Bowers earlier mention about the Vet Centers, are they all fully 

staffed and running as well? 

Dr. ZEISS. We will turn to Mr. Flora then first. 

Mr. FLORA. Well I am happy to tell you that, and I’m sure that 

you know that we’re adding 23 new Vet Centers and adding clinical 

staff at 61 existing Vet Centers. 

And I am happy to report that 20 of those Vet Centers are 

staffed and seeing clients. Some of them are still in temporary 

space. They are waiting for the contracting for the lease, for the 

property to get resolved, and only three of them are left to bring 

up. They will all be up before the end of this year. And staff are 

rapidly being hired in those remaining three and they’re working 

diligently on the leasing process. 

So we should be up and running with all 23 new Vet Centers before the end of this fiscal year. 

Mr. MICHAUD. And what about the existing Vet Centers, are they 

fully staffed? 

Mr. FLORA. Eighty percent done. 

Mr. MICHAUD. And what’s that twenty percent as far as numbers? And when will they be fully staffed? 

Mr. FLORA. Very soon. At the end of this fiscal year. 

Mr. MICHAUD. Okay. Thank you. And Dr. Allen? 

Dr. ALLEN. I am still relatively new at VA. I suppose coming into 

this system there are several things that I am impressed with that 

we are doing a very good job on. One of them is the screening for 

alcohol problems. 

I know of no system in the United States that does the amount 

of screening for alcohol problems as the Veterans Administration 

does. Right now we are screening close to 100 percent of individuals who access our system. At the time they access the system 

and annually thereafter. 

As has been brought up by previous panels the importance of 

doing brief intervention is to try to address alcohol problems in 

their earlier stages when they are, in fact, more malleable. This is 

coming along extremely well. Right now we have 98, what we refer 

to as ‘‘primary care mental health service’’ providers. In many 

cases, more than one provider is at a facility. But in this arrangement the mental health provider is coordinated directly with the 

primary healthcare staff. And so the brief intervention is done onsite and if the veteran does not respond to the brief intervention 

we certainly hope they will and the data are quite favorable then 

they are referred to specialty care. So I think that’s quite good. 

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Another area that has been developing quite well has been the 

use of buprenorphine. There was a comment made about that there 

was not adequate use of methadone. It is true, our numbers for 

methadone maintenance have remained pretty constant since about 

2004. But the number of patients who are now on Buprenorphine 

has increased by a factor of 4. Buprenorphine can be given in a primary healthcare center. And part of the advantage of that, is to diminish some of the stigma of going to a specific methadone maintenance program. 

Another area that I think we are doing extremely well in is in 

the ‘‘clinical practice guideline’’ arena. The Department of Defense 

and the Veterans Administration together do clinical practice 

guidelines, based upon to the extent possible, the best research evidence. And when it is not, when we simply do not have the evidence, then it is based on informed clinical opinion. The new substance use disorder guidelines for DoD and VA are nearly complete. 

We expect them to be complete within the next 6 years. I’m sorry, 

the next 6 months. 

I have reviewed the draft and it is quite good and I think addresses a number of the concerns about quality. This topic of addiction is actually quite heavily researched. There are now probably 

close to 300 controlled clinical trials on what works in treatment, 

and it is because of that the VA is committed to propagating and 

developing training programs on evidence-based treatments for addressing substance use disorders. 

The other topic I would like to address, which has been raised 

by a number of the other witnesses, has to do with the nexus between PTSD and substance use disorder. These problems do often 

co-occur. And in fact some of research suggests that when you have 

an individual, a returning servicemember, who suffers both problems the treatment prognosis is worse for both problems than if 

you had substance use with another psychiatric problem or if you 

had ‘‘pure’’ substance use disorder. 

So we are trying to address these together. Right now we have 

in all of our medical treatment facilities a team of providers who 

are dedicated to PTSD. On 12 of those teams we have a substance 

use disorder specialist and we have plans of adding this kind of resource to all of the other teams. The important thing, I think, with 

the treatment of substance use and collateral psychiatric problems 

is the care needs to be coordinated. Either done in an integrated 

fashion or else at least coordinated in a sequenced way where you 

would have a case manager who would assure that both kinds of 

care are being given. But, in short, my initial impressions of this 

system have been quite favorable. 

Mr. MICHAUD. Well I have several more questions, but I will recognize Ms. Berkley. 

Ms. BERKLEY. Thank you, Mr. Chairman. 

I work very closely with my VA back home and I know what a 

challenging job you have, and I thank you for all of your efforts on 

behalf of our vets. And I know sometimes our veterans have unrealistic expectations of what can be provided, and we’ve tried to 

have very frank discussions with veterans that call my office making requests that we can’t possible fulfill. 

wwoods2 on PRODPC68 with HEARING

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There was a time a few years ago and the head of the VA sat 

here presenting his budget, which was several billion dollars less 

than The Independent Budget that the veterans organizations provided to Congress, and we kept questioning the VA secretary of 

how could he possibly do what needs to be done with the budget 

he is presenting. And he assured us that the budget was fine. We 

practically threw an extra billion dollars at him, which he respectfully refused and I think it was going to be through attrition or 

technology that we would save all these billion of dollars and have 

plenty of money to take care of our vets. Six months later he was 

sitting where he was 6 months before asking us for that billion 

that we had asked him if he needed 6 months earlier that he assured us he did not need. Well, he needed it. And I’ve sat in hearings with the head of the U.S. Department of Agriculture that assured us that there were no additional funds necessary for inspectors, and then the following week we saw those horrific pictures on 

television of the down cattle and we are told that they did not have 

enough inspectors, which one shakes their head and says what. 

They have a perfect opportunity to be sitting in front of Congress 

and tell us what the needs are and they chose not to. With billions 

of dollars of toys that are coming into this country and toothpaste 

and other products from China, when the head of the consumer 

products safety commission tells us that she does not need additional inspectors, you have got to think that this woman ought to 

be fired, or is smoking one of the substances that we are talking 

about today. 

So my question to you is, if we were living in a perfect world, 

and there were unlimited resources and you can come before a 

Congressional Subcommittee and tell us what you need from us so 

that you can do the job that we have tasked you with, what would 

you tell us you needed? 

Dr. ZEISS. Well I would respond first by pointing out that the 

percentage increase in VA population that we are serving, has been 

about, I can submit the specific numbers later, has been about 3 

percent and the budget increase over the last 3 years has been 

about 15 percent. 

So the budget increases have been running well ahead of the increased work load, and personally as I said earlier, I think that we 

have appropriately devoted a large amount of that to correcting decline in mental health and substance abuse services that had previously developed. And I will actually point out Dr. Dick McCormick, who was on an earlier panel, when he was with VA was very 

instrumental in helping to focus and start things on a path that 

I’m thrilled to be a part of implementing. 

At this point I think that what we are actually planning to come 

forward with is that, the resources that we have been getting have 

been primarily medical care dollars and we have been using them 

intensively for very effective hiring and expansion of our mental 

health workforce, but we have lagged in terms of getting from Congress medical facility dollars. 

All those 3,800 new staff need offices. They need places to see 

veterans. They need renovations, sometimes, in space. So there are 

a number of needs in terms of medical facility dollars, and we are 

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actually planning to submit a white paper in relation to some upcoming thoughts about budget. 

So I would say for me, that is the really the main thing that 

would be tremendously helpful to us as we have grown so enormously. 

Ms. BERKLEY. Let me ask you another question, and I do not 

know if anybody can answer this, but I am sure you were in the 

room when I shared the story of Justin Bailey. 

Dr. ZEISS. Yes. 

Ms. BERKLEY. How does something like that happen, and what 

can we do in the future to prevent it? I mean, I have introduced 

this legislation. Is this the end-all-be-all cure for something like 

this. I had gotten to know his family very well. His father is a 

schoolteacher in our school district. This is a solid family and I 

could feel it. I have two sons and I could just imagine the pain that 

they feel on daily basis. What went wrong and what can we do to 

prevent it from happening again, so other families do not experience this horrific loss? 

Dr. ZEISS. Thank you for raising it. I wanted to raise it 

proactively if you had not, because it was clearly a terrible event. 

I personally went out to the LA Veterans Affairs Hospital along 

with a team, particularly the leadership of the residential rehabilitation staff. We did a very careful analysis of the what had gone 

wrong and you are quite correct. There were some issues around 

medication—not mental health medication, it was pain medication, 

but it could and should have been handled differently. 

We left a number of recommendations that were essentially requirements with that VA, and we also came back and generated resources to get out to them so they could implement those recommendations. And the handbook for the residential rehabilitation 

treatment programs was rewritten, particularly with even stronger 

emphasis on a staged model of self-medication, which had already 

been there, but needed real strengthening. That handbook is going 

to final concurrence within VA, but in the meantime, even before 

final concurrence, the staff that guide residential rehabilitation 

have been implementing this. There has just been, 2 weeks ago, a 

conference for the leadership of the residential rehabilitation treatment programs and will continue to be similar things. 

And I personally went out about 3 weeks ago to Los Angeles 

again, to follow up and make sure that things were being changed 

that needed to be changed. 

I think the other huge issue there was that, that was a domiciliary-type of residential rehabilitation program, and as part of the 

mental health strategic plan, the domiciliary switched from, Geriatrics and Extended Care to Mental Health. Even before a Department of Veterans Affairs had existed, there had been a Domiciliary 

Program. It had been under geriatrics and extended care within 

Veterans Health Administration and one of the recommendations 

of the strategic plan was to transfer that to the Office of Mental 

Health Services. That did happen in 2005. 

There had been some sites that have had more difficulty shifting 

their model of care to one of recognizing that these are really mental health programs. By the way, one of the reasons for that shift 

is that we had data showing that over 90 percent of the residents 

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of the domiciliaries had a mental health or substance use disorder 

diagnosis. So clearly there needed to be a different model of care. 

So I assure you we have been reorganizing the reporting mechanisms, the funding mechanisms, the guidance and oversight at 

those residential rehabilitation facilities because we agree with you 

that it is just not acceptable for something to happen like what 

happened to Justin Bailey. 

Ms. BERKLEY. Mr. Chairman, before Mr. Hare left he said I could 

have his five minutes. Could I take two of his five? 

Mr. MICHAUD. No problem because I have more questions as 

well. So feel free. You can take all of his five. 

Ms. BERKLEY. I am sure he said that as he walked out. 

Mr. MICHAUD. You can take all of his five you would like. 

Ms. BERKLEY. I do not think I need to, it depends on their answers. 

Let me share with you another gut-wrenching story. When anybody dies from the State of Nevada whether they live in my Congressional district or not, if they lose their life in service to our 

country I call the families, and offer any help that I could provide 

and just talk to them, and just sometimes they just—actually most 

of the people need hotel rooms in Las Vegas because they have got 

family coming for the memorial service, and we try to help and the 

hotels have been very accommodating. 

One phone call I made was to a grandmother in Pahrump, Nevada, which is a bedroom community about fifty minutes from Las 

Vegas. She had raised her grandson, so she was the appropriate 

person to call when he killed himself in Iraq. 

This was the story that she shared with me, although I knew it 

before I called her. 

Her grandson had served a tour of duty in Iraq, came home and 

3 months later he was advised that he would be shipped back. He 

was having serious emotional problems, did not want to go back. 

Begged his grandmother to do something to keep him from going 

back. He was interviewed by a psychologist or psychiatrist with the 

DoD who diagnosed him as being depressed and gave him Prozac 

and sent him back to Iraq. 

He was on suicide watch in Iraq. They knew that he had an emotional problem and he was suicidal. After a certain amount of time 

they took him off of suicide watch and the following day he killed 

himself. 

Now, had he not killed himself, and had completed his tour and 

come home, he would have been an emotional basket case that 

needed intervention and help. 

I know that our military is very stretched right now. Do you 

think that we are accepting into our volunteer military and keeping people that should not be there because of emotional problems, 

just so we have bodies on the ground in Iraq and Afghanistan? And 

do you see an uptick in those type of cases of people that should 

never be serving in the first place, so if they can get through their 

tour and they come home as veterans, they become, and I don’t 

mean to—when I say burden I don’t mean this is a negative sense, 

but I would imagine we have a number of people currently with 

PTSD and other emotional issues and substance abuse issues, that 

never should have been in the military in the first place. Are you 

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seeing any of that? I’m not asking to step out of your role and 

speak policy, could have, would have, should have, but I am kind 

of wondering, are you seeing an uptick in this? Are there people 

that are now coming into the VA as veterans that never should 

have been in the active military in the first place? 

Dr. ZEISS. Well I am going to say I am not going to speak to 

whether or not they should have been in the military in the first 

place. Those are decisions for a different department and our job 

is to take care of people when they return. 

I am happy to talk about what we are seeing among veterans 

who are returning, and what we have put in place and will continue to enhance. 

We certainly see a high number of returning folks who do have 

mental health problems. At this point there are 300,000 returning 

Iraq/Afghanistan veterans who have sought care from VA, and of 

those—no that is overall—and of those 40 percent have been potentially diagnosed with a mental health concern. Some of those are 

rule out diagnosis and will not be final diagnosis, but at least they 

need careful evaluation because of possible mental health problems. 

So that is about 120,000 folks, and of those about half have a 

possible PTSD diagnoses. The second largest is depression. The 

third largest is if you put all the substance use disorders together 

they would make up the third largest category of diagnosis. 

So there is no question that VA is seeing a high rate of mental 

health concerns in those veterans who seek care from VA. We can 

only speak to those who come and to service us. But we follow 

those data very carefully. We get quarterly reports on the increased 

number of veterans that we are seeing Iraq and Afghanistan and 

what are the major diagnosis that they are coming back with. Not 

just mental health but overall because it is important to integrate 

the mental healthcare with the other kinds of physical healthcare 

that these veterans have. 

So I assure you we are very carefully attending to what is the 

information about the breadth of problems that people return with, 

and what does that mean we need to be ready to do. 

Mr. MICHAUD. Earlier in my opening statement, I talked about 

reports out there that suggest that up to 70 percent of homeless 

veterans have a substance use disorder. What specifically is the VA 

doing to address this disorder among our homeless veterans? 

Dr. ZEISS. Well we are doing a number of things. Again I can 

speak first, and then I will let my colleagues also address this. 

We do not have with us Paul Smits, who is the head of our homeless section in the Officer of Mental Health Services. A splendid 

person who has, I know, testified many times. 

We have a large expanding homeless outreach and homeless 

service program that includes many dimensions of care. It includes 

the residential rehabilitation programs, domiciliaries, grant and 

per diem programs. We have a new U.S. Department of Housing 

and Urban Development—Veterans Affairs Supportive Housing 

Program that has been funded by Congress that we are in the process of implementing. And they do extensive outreach, along with 

the outreach that we can let Mr. Flora speak about that the Vets 

Centers do so splendidly. 

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We have many programs that are specifically designed to work 

very particularly with substance use disorder in homeless populations. 

I would say—I am sorry Ms. Berkley has left—one of the things 

that is a strength of the LA VA where Justin Bailey’s unfortunate 

death occurred, is that they take in homeless substance-using veterans who are extremely high risk and where that community has 

documented several times in newspapers stories other parts of the 

private healthcare system dumping people back on skid row. The 

VA has never done that, will never do that, and keeps people who 

are at very high risk in our treatment programs. 

Mr. MICHAUD. You mentioned the grant and per diem problem. 

I know from talking to the folks that deal with that program, there 

is also a problem with grants and per diem depending on what region of the country that you live in, as far as their reimbursement 

rate. Are you working with these organizations as well to make 

sure that they are adequately reimbursed? 

Dr. ZEISS. I know that Paul Smits is working very much on that 

and I’m not the expert on that, but, yes, it is certainly something 

that is followed carefully. 

The other important thing about the grant and per diem program, I just want to stress that may not come up in those discussions about the reimbursement, is that we fund from our mental 

health enhancement budget the liaisons that go out to those grant 

and per diem programs, which are not VA programs per se, to 

make sure that those homeless veterans get linked into our VA 

substance use disorder and mental health programs and who function as case managers. 

So it is above and beyond just providing the place to live that is 

reimbursed through the grant and per diem funding that you were 

mentioning. It is a much more complex program than that. 

Mr. MICHAUD. You heard Mr. Bowers talk about this this morning, and you mentioned it several times that you are addressing 

the needs of those who actually come forward for assistance, however there are a lot out there that do not, and Mr. Bowers said, 

I think, it took him like 3 years before he actually had the information that he really thought was helpful for a veteran to be able to 

get the services that they need. And he actually recommended that 

it be mandatory that they go through that type of coming back 

home with different programs. 

Do you agree with that, that they should be mandatory? I guess 

it gets back to my earlier statement that I am very pleased that 

Dr. Kussman actually issued a directive that VA facilities to ensure 

that no veteran is denied PTSD treatment because of substance use 

disorder. So it leads me to ask, why did Dr. Kussman give that directive? Is it because they were being denied? And so if you could 

address that, and whether or not we should mandate that they receive the training that Mr. Bowers had mentioned a little bit earlier. 

Dr. ZEISS. Yeah. Well two wonderful questions. The first one, 

which is about the PDHRA screens, I am happy to ask Mr. Flora 

to respond to, because the Vet Centers are always there. 

Mr. FLORA. The Vet Centers and a representative from the VA 

Medical Center has been at every PDHRA event that has occurred 

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over the last couple of years. This is facilitated with the Department of Defense. We have Colonel Terry Washam, who is a VA employee, who is the main point of contact in the seamless transition 

group that sets these up. But we have been at every one of them. 

And also since 2003, 2004, the Vet Centers have undertaken a very 

aggressive outreach program. And I am sure you know we hired 

the 100th Global War on Terrorism Outreach Specialists and they 

have been extremely active at demobilization sites providing the 

kind of information that was talked about. And I was very gratified 

to hear Mr. Bowers say that he had an excellent relationship with 

the Vet Centers. I think he said locally, but he got exactly the kind 

of information that he needed. 

And if you would not mind, sir, I’d like to go back to the first 

question that you asked me, and say, we would be happy to provide 

you a detailed report about where we are with our new Vet Center 

resources. 

I’m absolutely sure about the new Vet Centers numbers, but we 

can tell you, where we are augmenting staff and give you a very 

detailed picture. 

[The following was subsequently received:] 

In February 2007, VA announced plans to increase the number of Vet 

Centers from 209 to 232 and to augment the staff at 61 existing Vet Centers by one staff position each. Based upon the criteria of having hired staff 

and providing services to veteran clients, 20 of the projected 23 new Vet 

Centers are currently open. All 23 Vet Centers will be open by the end of 

the fiscal year. Fifteen Vet Centers are fully open with a signed lease and 

hired staff, and are providing services to veterans in Binghamton, NY; Middletown, NY; Watertown, NY; Hyannis, CT; DuBois, PA; Gainesville, FL; 

Melbourne, FL; Macon, GA; Manhattan, KS; Escanaba, MI; Saginaw, MI; 

Grand Junction, CO; Baton Rouge, LA; Killeen, TX; and Las Cruces, NM. 

Five Vet Centers have hired staff and are providing client services, but 

are operating out of temporary space while they finalize their lease contracts. They are located in Toledo, OH; Ft. Myers, FL; Montgomery, AL; 

Everett, WA; and Modesto, CA. 

Three Vet Centers are actively pursuing and/or completing staff recruitment and lease contracting. In Berlin, New Hampshire, the lease has been 

signed and the Team Leader, Office Manager and one Counselor have been 

hired. VA has hired a Team Leader in Nassau County, NY, and Fayetteville, AR. 

The 61 existing Vet Centers selected for augmentation are Mobile, AL; 

Tucson, AZ; Anaheim, Concord, Corona, Fresno, Los Angeles, Sacramento, 

San Bernardino, San Diego, San Jose, Santa Cruz County, Ventura and 

Vista, CA; Boulder, CO; New Haven and Norwich, CT; Jacksonville, Palm 

Beach, Pensacola, Sarasota, Tallahassee and Tampa, FL; Honolulu and 

Maui, HI; Cedar Rapids and Sioux City, IA; Boise, ID; New Orleans and 

Shreveport, LA; Brockton, New Bedford, Springfield and Worcester, MA; 

Caribou, ME; Charlotte, Greensboro and Greenville, NC; Lincoln, NE; Trenton, NJ; Albuquerque and Farmington, NM; Rochester, NY; Cleveland and 

Columbus, OH; Oklahoma City, OK; Portland, OR; Harrisburg, PA; Austin, 

El Paso and San Antonio, TX; Provo, UT; Alexandria and Norfolk, VA; Spokane and Tacoma, WA; Madison and Milwaukee, WI; and Beckley, Princeton, and Wheeling, WV. Currently 49 (or 80%) of the augmented positions 

are filled. The remaining 12 positions are under recruitment and will be 

hired by the end of the fiscal year. 

The following chart provides additional information regarding where VA 

is in the context of rural healthcare. 

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End of Fiscal Year 2006 Enrollees and Patients * 

VA Sites by State and percent rural 

Total EOY06 

Enrollee 

Urban 

Enrollee 

Rural 

Enrollee 

Highly rural 

Enrollee 

Total EOY06 

Patient 

Urban 

Patient 

Rural 

Patient 

Highly rural 

Patient 

National 7,848,282 4,879,424 2,850,173 118,685 4,877,733 2,919,645 1,878,624 79,464% Total 62.2% 36.3% 1.5% 59.9% 38.5% 1.6%Alabama 148,220 67,954 80,266 0 90,727 41,007 49,720 0Alaska 24,695 12,934 3,703 8,058 12,700 6,940 1,745 4,015Arizona 181,233 116,668 59,704 4,861 110,960 69,146 38,991 2,823Arkansas 114,753 37,740 77,013 0 80,785 25,990 54,795 0California 638,769 530,070 106,432 2,267 353,793 287,553 64,841 1,399Colorado 107,864 74,541 26,974 6,349 63,213 42,444 16,650 4,119Connecticut 80,575 69,354 11,221 0 51,093 44,258 6,835 0Delaware 22,531 13,820 8,711 0 12,961 7,974 4,987 0DC 16,113 16,113 0 0 9,417 9,417 0 0Florida 637,881 510,316 127,565 0 426,443 337,559 88,884 0Georgia 223,736 131,388 92,348 0 128,983 71,908 57,075 0Hawaii 33,478 23,424 10,054 0 18,361 12,302 6,059 0Idaho 46,439 22,410 18,332 5,697 31,041 14,965 12,277 3,799Illinois 285,615 193,965 91,650 0 170,266 111,603 58,663 0Indiana 161,719 89,256 72,463 0 108,147 58,688 49,459 0Iowa 94,290 30,942 63,348 0 65,769 21,287 44,482 0Kansas 82,282 32,880 43,947 5,455 57,882 23,189 30,540 4,153

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Kentucky 131,155 50,975 80,180 0 89,009 33,783 55,226 0Louisiana 126,172 66,848 59,324 0 79,488 39,485 40,003 0Maine 50,610 10,428 39,100 1,082 36,817 7,263 28,763 791Maryland 126,809 100,329 26,480 0 71,304 55,886 15,418 0Massachusetts 132,529 120,286 12,243 0 77,558 70,342 7,216 0Michigan 184,417 108,574 75,223 620 115,772 65,499 49,820 453Minnesota 129,266 55,016 72,035 2,215 89,836 36,322 52,059 1,455Mississippi 95,968 26,773 69,163 32 66,915 17,585 49,307 23Missouri 178,250 82,667 95,583 0 121,713 53,962 67,751 0Montana 42,131 9,727 19,081 13,323 29,023 6,391 13,437 9,195Nebraska 60,765 23,746 31,163 5,856 40,838 14,695 21,951 4,192Nevada 86,337 66,523 12,064 7,750 52,324 39,789 7,735 4,800New Hampshire 37,107 15,377 21,730 0 24,774 9,963 14,811 0New Jersey 158,295 147,743 10,552 0 78,629 73,297 5,332 0New Mexico 67,513 31,260 27,916 8,337 45,149 20,917 18,240 5,992New York 460,464 334,594 125,682 188 232,308 162,853 69,361 94North Carolina 245,773 112,961 132,812 0 160,503 72,354 88,149 0North Dakota 25,201 8,811 10,518 5,872 16,549 5,723 6,811 4,015Ohio 304,456 194,686 109,770 0 186,240 117,788 68,452 0Oklahoma 120,601 47,267 72,347 987 78,603 29,498 48,480 625Oregon 115,387 52,163 58,358 4,866 76,514 33,288 39,896 3,330Pennsylvania 361,114 230,399 130,715 0 228,985 144,361 84,624 0Rhode Island 27,957 25,378 2,579 0 19,650 17,902 1,748 0

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End of Fiscal Year 2006 Enrollees and Patients *—Continued 

VA Sites by State and percent rural 

Total EOY06 

Enrollee 

Urban 

Enrollee 

Rural 

Enrollee 

Highly rural 

Enrollee 

Total EOY06 

Patient 

Urban 

Patient 

Rural 

Patient 

Highly rural 

Patient 

South Carolina 144,972 75,369 69,603 0 93,181 47,064 46,117 0South Dakota 38,675 10,046 17,440 11,189 28,529 7,309 12,724 8,496Tennessee 169,858 88,391 81,467 0 111,087 56,943 54,144 0Texas 570,121 364,420 198,450 7,251 361,386 224,353 132,167 4,866Utah 45,924 34,605 6,809 4,510 28,570 21,679 4,171 2,720Vermont 20,779 2,282 18,497 0 14,185 1,535 12,650 0Virginia 193,291 119,645 73,572 74 109,106 62,586 46,464 56Washington 158,147 111,232 45,375 1,540 86,285 60,340 24,960 985West Virginia 84,795 24,758 60,037 0 56,834 16,131 40,703 0Wisconsin 145,105 66,367 78,738 0 100,087 44,689 55,398 0Wyoming 23,892 7,173 6,413 10,306 16,462 4,890 4,504 7,068Puerto Rico 84,253 78,830 5,423 0 60,979 56,950 4,029 0

* Excludes non-enrolled non-Veterans and Priority 8e, 8g. 

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Mr. MICHAUD. Yeah, I appreciate that very much. 

Dr. ZEISS. In terms of the directive, we feel passionately about 

it and so I’m glad that you recognize it. And it does not just say 

that treatment for PTSD cannot be denied—it is any mental health 

problem. And the reason that it was released is because we knew 

not only of anecdotal reports of some people being refused treatments, but also that there were some programs who had policies 

that if someone was using substances they would not be eligible. 

That is reasonable and I’ll ask Dr. Allen to speak more to that. But 

it is not reasonable to say, therefore no care will be provided. That 

is absolutely unreasonable. The appropriate level of care needs to 

be provided. 

Dr. ALLEN. It is almost a patient ‘‘bill of rights’’, if you will, 

which says that substance use problems are always to be addressed, but they are to be addressed appropriately. For example, 

if you have a veteran that is in one of the residential rehabilitation 

treatment programs and the individual is actively using substances, that person may be transferred out of that facility because 

of the risk that he or she would present to other patients, but they 

are still treated. And in fact, if the veteran is approached on the 

need for care, and refuses, they are still called to see if things have 

changed. 

One other thing I would like to mention, the PDHRA event that 

was alluded to earlier, occurs 90 to 180 days post deployment. 

These events are set up by the Department of Defense, and, in fact, 

the PDHRA is mandatory for redeploying servicemembers. It is 

more difficult sometimes if it is a National Guard unit that is in 

a more remote site, or a Reserve unit, than if it is an active-duty 

unit, but they are mandatory. I went through it myself, in fact. But 

the VA is always there and the Vet Centers are always there with 

a representative. 

So we tried to tighten up that linkage. I do agree it does not always happen. It should not have been 3 years. It should have been 

90 days to 180 days after return. That is a problem in that unit. 

Mr. MICHAUD. You mentioned Guard and Reserve is more difficult, but yet when you look at the war in Iraq and Afghanistan 

with the number of redeployments and the length of redeployments 

and the fact that there are so many Guard and Reserves over 

there, how do you close that gap so that the Guard and Reserves 

are not hit and miss? 

Dr. ALLEN. There is supposed to be a dwell time, and I am sorry 

I do not know the DoD policy on that, but typically the redeploying 

servicemember is home at least as long as he or she was deployed 

previously. And I think, and again it is simply what the newspapers were indicating, yet there may be a requirement that it is 

twice as long as they were in the country. But there is a dwell time 

that the individual must be here. 

Mr. MICHAUD. Earlier, actually, I believe Dr. McCormick mentioned that there were gaps in services. But also if you look at 

what is happening nationwide, one facility might be doing a very 

good job, another facility is not doing a very good job, and hopefully 

we will come up with a report card on each facility. Do you see that 

variation between facilities as far as the actual services that they 

might be receiving or not receiving? 

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38 

Dr. ALLEN. At this point there is variability, but I can say that 

every VA Medical Center has a substance abuse treatment program. They differ in terms of the availability of residential rehabilitation programs and intensive outpatient programs. 

We have a staffing model for the intensive outpatient programs 

that looks at the number of veterans in an area, the percent that 

are dual diagnoses and helps us decide if it is warranted to set up 

an entire program there. If it is not, the services can be contracted 

out, and they can be contracted out to community agencies, and 

that would likely be the case in more remote parts of the country 

where you simply don’t have enough veterans for this to be under 

our roof. But there is a strong movement toward standardization 

of services. 

Apparently, at one time, the Veterans Administration became 

highly decentralized and so you have a tremendous amount of discretion at the regional levels. There is an effort now to look at better standardization of services and opportunities so that there will 

be certain treatment opportunities that must be made available to 

all veterans regardless of where they live, although the mechanism 

for providing them may well be a contract. It might be telemedicine 

or if there are enough people there it would be under our own roof 

but we are concerned about the problem. 

Mr. MICHAUD. When you contract out, how do you know, it there 

a witness test that you make sure that wherever you are contracting out? Because one of the things that we heard a few meetings ago is to make sure that we have qualified providers out there, 

and how do you determine that? 

Dr. ALLEN. Toni, Do you want to address that? 

Dr. ZEISS. Those decisions are made at the local level, so we can 

gather more information for you if you would like, but our role at 

central office is to indicate what are the kinds of services that need 

to be provided and to work with the local folks to determine what 

is the best way to provide it. 

The range of possibilities, I think, just to pull them all together, 

you’ve heard about them in a more scattered way, is first certainly 

for veterans to come to a VA Medical Facility where there will be 

the most complex and breadth of services. 

Second, to go to a community based outpatient clinic, where 

there are now mental health staff at most clinics, and get services 

there. There is telemental health, and you have been asking about 

some other more high-tech ways of delivering service, and we have 

been working on various fronts with that. But telemental health is 

a way to really link people to more specialized care at the medical 

facility who are out getting their care from community based outpatient clinics. And then ultimately, if someone is really too far 

away even from a community based outpatient clinic, there is the 

possibility to contract care. And the requirement is that the local 

facilities develop memorandums of understanding that clearly lay 

out what are the kinds of services and who are the providers. But 

we don’t require that those be approved at the national level. 

Something else, but let me stop there and see what questions 

that raises. 

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Mr. MICHAUD. Yes, back in, I believe, 2006, the VA did a PTSD 

Report. When is the next report due out? Do you have another report? The special Committee? 

Dr. ZEISS. If you mean the report of the special committee, it is 

annual, and I think that the current one, if it has not been released 

to Congress, it is in its final review prior to that release. 

Mr. MICHAUD. Okay. 

Dr. ZEISS. Is it still in review. Yeah. Okay. So it is forthcoming. 

Mr. MICHAUD. You heard my questions earlier about the Surgeon 

General and the Deputy Undersecretary when they were talking to 

the VFW and it was brought to my attention from a veterans service organization, that they have this new classification or it is at 

least the first time I ever heard of it, PTSD–NR. What is PTSD– 

NR? 

Dr. ZEISS. It was the first we had heard of it, too, and I suspect 

they were referring to the Diagnostic and Statistical Manual of 

Mental Disorders (DSM) IV, revised version. We use the most recent version of DSM IV for making PTSD diagnoses. 

I don’t think that is NR, it is DSM IV R. But that may have 

snuck in. But I believe that is probably what they were talking 

about. I will go back and check. 

We use the diagnostic and statistical manual of the American 

Psychiatric Association as the absolute basis for the PTSD diagnosis. 

[After researching the term, the VA was unable to find out the 

origination or definition of the term, PTSD–NR.] 

Mr. MICHAUD. Right. And just the last few questions. 

As you know treatment of comorbid substance use disorder and 

other mental health conditions are very challenging, how does the 

VA ensure that they have the mental health professionals that are 

competent to treat these comorbid conditions and what research is 

VA doing on comorbid conditions? 

Dr. ZEISS. Do you want to start with this? 

Dr. ALLEN. Certainly. 

Well I think this is probably a question we should have for the 

record. 

The comorbidity thing is a difficult issue. I know that for our 

clinical psychologists, and we have increased the number of those 

people a lot, they have to be extremely well qualified. They must 

be licensed in the State. They must have taken their doctorate in 

a program that is approved by the American Psychological Association (APA), and their internship must be in a program approved by 

the American Psychological Association. 

So I think our standards are extremely high for our professional 

staff. Does that guarantee that they could treat comorbid conditions? I think so. If they are at that level that is what they have 

been licensed to do, and it is a challenging area. We obviously need 

to get smarter and better always. 

Dr. ZEISS. Let me just, for the record, fine-tune just a bit what 

Dr. Allen has said. 

For psychology and social work where professionals are not licensable until 1 to 2 years after they have completed their internship, VA can hire unlicensed psychologist and social work staff, but 

they must be professionally supervised during the period while 

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they are completing licensing. And they must complete licensing 

within a short period of time if they are going to be able to maintain VA employment. 

So I think I would echo strongly what Dr. Allen is saying about 

the high credentials of our staff and especially the requirement 

that people have all their training from APA credited programs. 

The other thing I would say, is we know, again focusing specifically on psychology, that of recent hires in the last year to 2 years, 

of new psychology staff, over 75 percent of them have had training 

in VA before they were hired. And so they were getting at least 

part of their training, exactly with veterans who have a high rate 

of comorbid problems, and these trainees then enter our staff already with supervised experience in working with the nature of the 

problems that veterans present. And we happen to have that specific number for psychology. It is true for other professions, as well, 

because of the large training program that VA has. 

Mr. MICHAUD. What do you do in a situation since that standard 

is very high, and if a veteran that lives in a rural area might need 

that type of assistance, it is going to be very difficult because you 

might not have a provider that you would be able to contract out. 

So how do you close that gap in those particular situations? Do you 

have a handle on exactly how big that gap is? 

Dr. ZEISS. Well, we have an Office of Rural Health and we can 

take, for the record, specific questions. I have looked recently at 

their data and we know that the highly rural veteran population, 

which is defined by the number of folks per square mile or per 

acre—is 1.6 percent of the veteran population. But there are States 

where it is a much higher proportion and we are really looking to 

the Office of Rural Health to help guide us. And in fact I think they 

have recently submitted a plan for mental health and geriatric care 

to Congress based on their extensive analysis and collaboration 

with us. 

As I mentioned, the range of possibilities includes to expanding 

telemental health. I think the question you have asked earlier, is 

Internet-based therapy useful or not, and we would re-construe 

that question as what aspects of care can be provided effectively on 

an Internet basis. We have My HealtheVet, which is a web based 

set of rich information and screening information that veterans can 

access from their home computer. And it allows them to get some 

educational information about mental health and substance problems and to do some self screening. 

We are also working to develop the interactive capacities between My HealtheVet and medical facilities. 

So there could be secure messaging between providers and veterans. But we are not completely there yet, so that is being currently tested in the primary care context. 

So we think there are lots of avenues we need to pursue as we 

have been pursuing, to keep pushing the window and being able to 

do a better and better job with these rural veterans, who clearly 

face the most difficult obstacles in terms of getting care from VA, 

but also as you say, many of these communities do not have rich 

other resources for mental health and substance use care. 

Mr. MICHAUD. I want to thank you very much Dr. Zeiss, and Dr. 

Allen and Mr. Flora for your testimony today. I look forward to 

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41 

working with you and I know we will have some more follow up 

questions. This is a very important issue to Members of this Committee and it is one that we hopefully will be able to get a better 

handle on as we move forward to make sure that our veterans do 

receive the services that they need in a timely manner and that 

they have access to those services as well. 

So once again, thank you very much for your testimony today, I 

appreciate it. 

Dr. ZEISS. Thank you. 

Dr. ALLEN. Thank you. 

Mr. FLORA. Thank you. 

Mr. MICHAUD. No further questions. The hearing is adjourned. 

[Whereupon, the Subcommittee was adjourned at 12:00 noon.] 

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A P P E N D I X 

Prepared Statement of Hon. Michael H. Michaud 

Chairman, Subcommittee on Health 

I would like to welcome everyone to our Subcommittee hearing. We are here today 

to talk about treatment for substance abuse and comorbid conditions in the Department of Veterans Affairs. 

Substance use disorders are among the most common diagnoses made by the Veterans Health Administration. According to the 2007 National Survey on Drug Use 

and Health, 7.1% of veterans met the criteria in the past year for a substance use 

disorder and 1.5% of veterans had a co-occurring substance use disorder. Of the approximately 300,000 veterans from Operations Enduring and Iraqi Freedom who 

have accessed VA healthcare, nearly 50,000 have been diagnosed with a substance 

use disorder. 

Additionally, more than 70% of homeless veterans suffer from alcohol and other 

drug abuse problems. 

Over the past several years, Congress has increased funding for substance use 

treatment programs within the Department of Veterans Affairs to $428 million in 

Fiscal Year 2008. I believe that continued adequate funding is imperative for the 

health and well-being of our veterans and their families. 

Substance use frequently co-occurs with other mental health conditions. VA needs 

to continue to dedicate itself to providing services that can address both substance 

use and other mental health conditions such as PTSD simultaneously. 

I also was pleased to learn that Dr. Kussman, VA’s Undersecretary for Health recently released a directive on the management of substance use disorders. This directive states, among other things, that VA facilities must not deny care to any enrolled veteran because they are using substances and that all VA medical facilities 

must provide services to meet the needs of veterans with substance use disorders 

and PTSD. I think that this is a step in the right direction and I commend VA for 

it’s proactive leadership on this issue. 

Last week, Mr. Miller and I introduced the Veterans Substance Use Disorder Prevention and Treatment Act of 2008. This legislation will require the VA to provide 

the full continuum of care for substance use disorders, and it will require this full 

spectrum of care to be available at every VA medical center. This legislation also 

directs the VA to conduct a pilot program for Internet-based substance use disorder 

treatment for veterans of Operations Enduring Freedom and Iraqi Freedom. This 

will enable our newest generation of veterans to overcome the stigma associated 

with seeking treatment and receive the necessary care in a comfortable and secure 

setting. 

The Committee realizes that substance use and comorbid conditions are complex 

issues. But we also recognize that it is an important one that deserves serious 

thought and consideration. I look forward to hearing from our panels today about 

ways that VA can effectively address these critical issues. 

f 

Prepared Statement of Hon. Shelley Berkley, a Representative in Congress 

from the State of Nevada 

Mr. Chairman, 

Thank you for holding this hearing on this important issue of substance abuse 

and comorbid conditions. 

Nationally, one in five veterans returning from Iraq and Afghanistan suffers from 

PTSD. Twenty-three percent of members of the Armed Forces on active duty acknowledge a significant problem with alcohol use. It is vital that our veterans receive the help they need to deal with these conditions. 

The effects of substance abuse are wide ranging, including significantly increased 

risk of suicide, exacerbation of mental and physical health disorders, breakdown of 

wwoods2 on PRODPC68 with HEARING

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family support, and increased risk of unemployment and homelessness. Veterans 

suffering from a mental health issue are at an increased risk for developing a substance abuse disorder. 

A constituent of mine, Lance Corporal Justin Bailey, returned from Iraq with 

PTSD. He developed a substance abuse disorder and checked himself into a VA facility in West Los Angeles. After being given 5 medications on a self-medication policy, Justin overdosed and died. 

I have introduced the Mental Health Improvements Act, which aims to improve 

the treatment and services provided by the Department of Veterans Affairs to veterans with PTSD and substance use disorders by: 

• Expanding substance use disorder treatment services at the VA Medical Centers. 

• Establishing national centers of excellence on PTSD and substance use disorders. 

• Creating a program for enhanced treatment of substance use disorders and 

PTSD in veterans. 

• Requiring a report on residential mental healthcare facilities of the Veterans 

Health Administration (VHA). 

• Creating a research program on comorbid PTSD and substance use disorders. 

• Expanding assistance of mental health services for families of veterans. 

It is imperative that we provide adequate mental health services for those who 

have sacrificed for this great nation and those who continue to serve. This bill takes 

a step in the right direction in providing our veterans with the care they have 

earned. I urge my colleagues to cosponsor this important piece of legislation, and 

I look forward to further action in this Committee. 

f 

Prepared Statement of Hon. John T. Salazar, a Representative in Congress 

from the State of Colorado 

Good morning Mr. Chairman, Ranking Member Miller and distinguished members 

of this subcommittee. 

I look forward to discussing the incidence of substance abuse and associated conditions plaguing our nation’s veterans. 

Our servicemen and women put their lives on the line to ensure that our nation 

is safe and that our freedoms are protected. 

Unfortunately, the battle is not always over once these brave men and women return home. 

The stress of wartime service puts our returning troops and veterans at risk for 

mental illness such as PTSD and Substance Use Disorder. 

The rates of mental illness among service members are on the rise. 

It is likely that the demand for mental health services will continue to grow 

among soldiers returning from active combat. 

The 2007 National Survey on Drug Use and Health showed us that too many of 

our veterans suffer from Serious Psychological Distress and substance use disorder. 

I am eager to hear today’s testimony from the experts in veteran healthcare that 

are present. 

I also look forward to your opinions regarding the legislation that addresses the 

issues we will discuss here today. 

Thank you, Mr. Chairman, for the opportunity to discuss these issues that so 

many of our veterans face on a daily basis. 

f 

Prepared Statement of Patricia M. Greer 

President, NAADAC, the Association for Addiction Professionals 

Mr. Chairman, I would like to thank you and the members of this subcommittee 

for holding today’s hearing on ‘‘Substance Abuse/Co-Morbid Disorders: Comprehensive Solutions to a Complex Problem.’’ The challenges in creating a healthcare system capable of effectively treating co-occurring substance use disorders are significant, but experience has proven that there are practical steps which can improve 

outcomes for clients and their families. 

As a brief note of introduction, NAADAC, the Association for Addiction Professionals, is the national professional association serving addiction-focused health professionals and educators. NAADAC has 10,000 members across the country and affiliate organizations in 46 states, two territories, and several foreign countries. Our 

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1Quoted in Smith, Thurston. ‘‘Overview.’’ Resource Links: Substance Use Disorders and the 

Veterans Population. Northeast Addiction Technology Transfer Center. Summer 2004. Vol. 3, 

Iss. 1. 1 National Survey on Drug Use and Health. ‘‘Serious Psychological Distress and Substance 

Use Disorder among Veterans.’’ Office of Applied Studies, Substance Abuse and Mental Health 

Services Administration. 1 Nov. 2007. 2 National Survey on Drug Use and Health. ‘‘Serious Psychological Distress and Substance 

Use Disorder among Veterans.’’ Office of Applied Studies, Substance Abuse and Mental Health 

Services Administration. 1 Nov. 2007. 3 National Survey on Drug Use and Health. ‘‘Alcohol Use and Alcohol-Related Risk Behaviors 

Among Veterans.’’ Office of Applied Studies, Substance Abuse and Mental Health Services Administration. 10 Nov. 2005. 4 National Survey on Drug Use and Health. ‘‘Serious Psychological Distress and Substance 

Use Disorder among Veterans.’’ Office of Applied Studies, Substance Abuse and Mental Health 

Services Administration. 1 Nov. 2007. 5Quoted in Danforth, Kristen Inger. ‘‘Change in Mindset Brings Veterans Care Into a New 

Era.’’ Resource Links: Issues Facing Returning Veterans. Northeast Addiction Technology 

Transfer Center. Fall 2007. Vol. 6, Iss. 1. 6 National Survey on Drug Use and Health. ‘‘Serious Psychological Distress and Substance 

Use Disorder among Veterans.’’ Office of Applied Studies, Substance Abuse and Mental Health 

Services Administration. 1 Nov. 2007. 7Mwisler, A.W. ‘‘Trauma, PTSD and Substance Abuse.’’ PTSD Research Quarterly, 7, (4). 

8 Hope Yen. ‘‘Pentagon Panel Warns of Mental Strain.’’ Associated Press. 3 May 2007: http:// 

vawatchdog.org/07/nf07/nfMAY07/nf050507-1.htm. and ‘‘Mental Health Advisory Team (MHAT) 

IV Brief.’’ General James T. Conway, Commandant of the Marine Corps. 18 April 2007: http:// 

216.239.51.104/search?q=cache:505MsjAlGO4J:blog.wired.com/defense/files/mhat_iv_brief_to_ 

marine_corps_commandant_gen_conway_18apr07.ppt+Mental+Health+Advisory+Team 

+(MHAT)+II+Brief&hl=en&ct=clnk&cd=1&gl=us. 

certification commission certifies addiction professionals in all fifty states and in numerous foreign countries. 

Scope of Substance Use Disorders and Co-Morbidity 

In 2004, Dr. Richard Suchinsky, Department of Veterans Affairs Associate Chief 

for Addictive Disorders, ranked substance use disorders among the three most common diagnoses made by the Veterans Health Administration (VHA).1 Nevertheless, 

they remain under-diagnosed and under-treated in the VHA, which reflects a similar treatment gap in civilian society. Young veterans (under age 25) suffer from substance use disorder rates as high as 25 percent,2 and veterans are more likely than 

their civilian peers to engage in heavy alcohol use and to take part in risky behavior 

like drunk driving.3 In total, it is estimated that 1.8 million veterans suffered from 

a diagnosable substance use disorder in 2002 and 2003.4

Substance use disorders frequently co-occur with other physical and mental health 

conditions. In the case of diseases like HIV or hepatitis-C, co-morbidity with substance use disorders is often associated with the act of drug use itself—sharing needles, for example, or engaging in risky sexual behavior. In the case of mental health 

conditions like post-traumatic stress disorder (PTSD), depression, or bipolar disorder, substance use disorders frequently result from attempts to ‘‘self-medicate’’ 

with alcohol or other drugs rather than receiving needed mental healthcare. 

The high number of mental health conditions reported by veterans of the conflicts 

in Iraq and Afghanistan has been associated with a surge of co-occurring substance 

use and mental disorders. Some experts estimate that about 40 percent of veterans 

who have served in Iraq or Afghanistan will experience a mental health problem, 

and that of those approximately 60 percent will have a substance use disorder.5 In 

2002 and 2003, the National Survey on Drug Use and Health estimated that 

340,000 male veterans suffered from co-occurring substance use disorders and ‘‘serious mental illness,’’ defined as a diagnosable mental condition that substantially 

interfered with a normal life activity.6 Post-traumatic stress disorder—one of the 

most commonly diagnosed combat-related mental disorders—is frequently co-morbid 

with substance use disorders. During the Vietnam War, for example, 60–80 percent 

of veterans with PTSD also suffered from addiction disorders.7

There is reason to fear that co-occurring substance use disorders in veterans may 

be on the rise. Studies have shown that multiple deployments increase the risk of 

post-traumatic stress disorder, and National Guard forces report higher rates of psychological distress than do regular forces.8 As redeployments continue and additional ‘‘citizen soldiers’’ serve overseas, the risk of co-occurring substance use disorders rise. 

Co-occurring substance use disorders are difficult to treat, and the ongoing stigma 

against addiction and treatment discourages many people from seeking the help 

they need. This is particularly true for people from the military culture who fear 

seeming ‘‘weak’’ or in need of help. 

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9 National Institute on Drug Abuse. ‘‘Principles of Drug Addiction Treatment: A Research 

Based Guide.’’ NIH Publication NO. 00–4180. 10Tracy SW, Trafton JA, Humphreys K. ‘‘The Department of Veterans Affairs Substance 

Abuse Treatment System: Results of the 2003 Drug and Alcohol Program Survey.’’ Palo Alto, 

Calif, VA Program Evaluation and Resource Center and Center for Health Care Evaluation, 

2004. Available at www.chce.research.med.va.gov/pdf/2004DAPS.pdf. 11McKeller, J., Che-Chin, L. & Humphreys, K. ‘‘Health Services for VA Substance Use Disorder Patients: Comparison of Utilization in Fiscal Years 2002, 2001 and 1998.’’ 2002. Palo Alto, 

Ca.: Program Evaluation and Resource Center and Center for Health Care Evaluation, Department of Veterans Affairs Medical Center. 

Delivering Comprehensive Care 

The Department of Veterans Affairs and Congress should be commended for having made mental health care for veterans a priority over the past several years. The 

publicly expressed concern for veterans with post-traumatic stress disorder, traumatic brain injury, and other mental health conditions has been far greater than 

in earlier conflicts. We thank Congress for its historic recent funding increases for 

veterans’ health, which have the potential to significantly expand access to treatment. 

As this hearing’s title aptly suggests, co-occurring addiction and mental disorders 

are best treated comprehensively. This means that caregivers are most effective 

when they have demonstrated competencies in both addiction and mental health 

care. Treatment for substance use disorders is most effective when delivered by 

health care professionals with a certification or license in addiction-specific care; research has shown that addiction treatment is as effective as treatment for other 

chronic diseases such as diabetes, hypertension, and asthma.9 Licensure and certification ensure that the practitioner has both the educational foundation and clinical 

experience in evidence-based and promising practices to provide the best possible 

care. 

A commitment by the VHA to prioritize treatment for co-occurring addiction and 

mental illness must include a commitment to expand and train its addictions-focused workforce—staff intended for addiction treatment at some veterans hospitals 

are often reassigned or transferred, resulting in uneven treatment in some cases. 

Reports that the addiction-focused VHA workforce has declined by almost half in the 

past decade are particularly disturbing.10 As the VA seeks to build its addiction 

treatment workforce, it should recruit addiction professionals who are certified or 

licensed in addiction treatment by their state of residence. The VHA should also 

provide resources to its current health care workforce to become certified or licensed 

in addiction-specific treatment. 

Whether the clinician treating a client with a co-occurring substance use disorder 

has demonstrated competencies in both addiction and mental health trauma or 

works in partnership with other clinicians, it is important that the client have access to both areas of medical knowledge. Once comprehensive treatment has begun, 

it should be extended as long as necessary. For example, in-patient treatment for 

co-occurring PTSD and addiction can take several months, and outpatient treatment 

can take a year or longer. As with any extended treatment, the patient’s family 

should be included in any treatment program whenever possible. 

Early screening and intervention lead to more successful treatment outcomes for 

co-occurring substance use disorders. Almost 500,000 of the veterans who received 

any form of VA care in 2001 are estimated to have met the clinical criteria for substance use disorders, yet only 19 percent of them (about 91,000) received specialized 

addiction treatment.11 This is primarily because these veterans presented at primary care facilities and their substance use disorders went undetected. Primary 

care health practitioners must be trained in identifying substance use disorders and 

co-occurring mental health conditions, and qualified addiction professionals should 

be on-call to provide intervention in cases where evidence of substance use disorders 

exists. 

Routine screenings must be conducted in a manner that encourages honest responses and results in a seamless transition into treatment. Similarly, the VA 

should be transparent and accountable for cases where they deny treatment to a 

veteran claiming to have combat-related PTSD or substance use disorders and release public reports on those statistics. Because PTSD and substance use disorders 

are often late-onset conditions, screenings should be conducted as regularly as possible in the years following a veteran’s return from combat. 

Once receiving treatment for co-occurring substance use disorders, it is critical 

that clients receive culturally competent care. Familiarity with military culture is 

often essential for effective treatment. This is true both for addiction professionals 

in the VHA as well as for the civilian addiction professionals who treat veterans 

who seek treatment in the nation’s non-VHA treatment systems. 

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12Schnurr, P.P., et al. ‘‘Cognitive Behavioral Therapy for Posttraumatic Stress Disorder in 

Women.’’ JAMA. 28 Feb. 2007. Vol. 297:820–830. and Kessler, T.C., Sonnega, A., et al. 

‘‘Posttraumatic Stress Disorder in the National Comorbidity Survey.’’ Arch Gen. Psych. Dec. 

1995. 52(12):1048–60. 13Drug and Alcohol Services Information System. ‘‘Characteristics of Substance Abuse Facilities Owned and Operated by the Department of Veterans Affairs: 2000.’’ Office of Applied Studies, Substance Abuse and Mental Health Services Administration. 11 Nov. 2002. 

The current conflicts in Iraq and Afghanistan also require a new emphasis on 

gender-specific treatment strategies. Fifteen percent of the armed forces are women, 

and servicewomen are closer to combat than ever before. Rates of PTSD are higher 

in women than in men, and female veterans suffer from PTSD in numbers greater 

than their civilian counterparts.12 The VHA should invest in studying gender-specific treatment and counseling strategies, and provide appropriate training to its addiction and mental health workforce. 

The unprecedented number of women serving in the armed forces, combined with 

the high rates of Reservists and National Guard forces in combat and extended 

tours of duty, have made the current conflict particularly psychologically difficult for 

families. Addiction is a disease which affects the entire family—there are powerful 

genetic predispositions for addiction, and family stress increases the risk of drug 

use. Such stress exists both when a parent or child is deployed as well as when they 

return from duty—the process of ‘‘returning to normal’’ is rarely as seamless as a 

veteran’s family might hope. In most cases, addiction treatment for a veteran should 

occur in the context of his or her family. The VHA should increase its outreach to 

family and include families in its treatment programs whenever possible. The VHA 

must prioritize family-centered care as it implements comprehensive care for comorbid substance use disorders. 

Part of this family-centered treatment approach includes making access to treatment as client-friendly as possible. Compared with the civilian system, both public 

and private, substance use disorder-specific care in the VA takes place in hospitals 

that are more densely populated, and less geographically dispersed, than civilian 

treatment sites. A study found that VHA facilities (mostly hospitals) providing addiction treatment housed three times as many clients, on average, than did nonVHA facilities.13 This indicates addiction treatment in the VA is more centralized 

in fewer, larger facilities than treatment in the civilian sector. This raises the concern that some veterans have more difficulty finding a convenient, easily accessible 

treatment site through the Department of Veterans Affairs than their civilian counterparts. This problem is particularly pronounced for veterans in rural areas and 

for those who lack the employment flexibility, funds, or family structure to travel 

long distances. 

Despite the significant funding increases for veterans’ health care, we encourage 

the Department of Veterans Affairs to more aggressively pursue partnerships with 

existing civilian treatment systems. No amount of new VA funding can rebuild the 

entire public and private treatment system which exists in the United States today, 

with well over 10,000 treatment facilities and tens of thousands of addiction professionals. The diminishing returns of such an attempt, particularly in rural areas and 

small communities, would not be an efficient use of funds. Rather, strategic partnerships that expand the capacity of existing treatment systems in underserved areas 

would provide veterans and their families with the care they need close to home. 

It would also expand access to care immediately, without the need for new facilities, 

employees, and programs to be established. 

Conclusion 

The current conflicts in Iraq and Afghanistan pose many new challenges to effective health care. While co-occurring substance use disorders and mental health conditions like PTSD are among the most complex of those challenges, comprehensive 

plans of action can dramatically improve veterans’ health. In this case, ‘‘comprehensiveness’’ includes ensuring that a clinician with addiction-specific qualifications is 

part of every treatment plan, that the family is included to the greatest extent possible, that screening and intervention for addiction and mental illness is included 

in primary care settings, and that veterans can access the care they need conveniently and close to home. We commend the Department of Veterans Affairs, this 

subcommittee, and other policymakers who have worked to improve veterans’ access 

to health care in the past several years. We look forward to working with other 

stakeholders to improve the nation’s treatment systems for co-occurring substance 

use disorders. Thank you for the opportunity to testify today, and I would be happy 

to answer your questions. 

f 

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Prepared Statement of Richard A. McCormick, Ph.D. 

Senior Scholar, Center for Health Care Policy and Research, Case Western 

Reserve University, Cleveland, OH 

Mr. Chairman, Ranking Member and Members of the Subcommittee, I will attempt in my limited remarks to provide an independent, ground level assessment 

of the needs of veterans for substance use disorder services, and the current capacity of VA to provide them. 

Let me first share the basis for my assessment. I retired a few years ago after 

32 years in VHA, where I worked clinically primarily in substance abuse and then 

in various management positions, culminating as Mental Health Care Line Director 

for VISN10. I was the co-chair of the VA national Committee on the Care of Severely Mentally Ill Veterans, mental health representative on the VACO Task Force 

overseeing all practice guidelines, and co-chair of the group drafting VA evidence 

based practice guidelines for Dually Diagnosed veterans. After I retired I had the 

additional opportunity to personally site visit 39 VA facilities as a member of the 

CARES Commission, a member of a special Secretary’s mental health task force established by Secretary Principi, and as consultant on mental health and substance 

abuse programming. The last two years I personally visited 23 military bases and 

reserve units, across the world, as a member of the congressionally mandated DoD 

Mental Health Task Force. On these visits I talked with literally thousands of service members, family, mental health providers and commanders about mental health 

and substance abuse issues. I continue to conduct NIAAA funded research at the 

Center for Health Care Policy and Research at Case Western Reserve University 

and am involved in two large DoD funded studies of returning National Guard and 

Reserve members. 

Scope of the Problem 

The need for comprehensive substance use disorder services is immense and growing. Multiple studies indicate high rates of alcohol and other drug related problems 

for returning service members. For example, returning reservists, who are veterans 

within weeks of their return, report rates as high as 52%, related to combat exposure, number of deployments. 

This hearing importantly focuses on comorbidities. Substance misuse is a common 

comorbidity for all significant mental and social problems afflicting veterans. The 

veteran must have access to comprehensive substance abuse services not only to 

deal with the symptoms, complex personal, family and social problems addiction 

causes, but also to be able to engage in treatment for these comorbid conditions. Engagement in state of the art PTSD treatment requires first or concomitantly treating a substance abuse problem in at least a third of patients presenting. Up to one 

half of veterans with serious mental illness also have a substance problem that complicates care. 

There is growing concern with suicidality. Military studies are consistent with VA 

long term studies linking suicidal behavior to substance misuse for many, if not 

most. 

Access to comprehensive substance disorder services is also crucial in providing 

care for non-mental health conditions that are a priority for veterans. For example, 

engagement in treatment for Hepatitis C requires abstinence, and continued heavy 

drinking has long term medical consequences. A common symptom in TBI is 

disinhibitory behavior, which is often manifest as substance misuse or its close cousin problem gambling. Again medical advice is for patients with TBI to stop drinking. 

VA’s priority mental health and medical programs cannot provide state of the art 

care unless they are complemented by comprehensive substance use disorder services. 

What is the state of substance use disorder care in VA? 

VA has been a leader in drafting evidence based treatment guidelines for substance use disorders. We know much about what works. 

In the past decade VA specialized access to substance abuse care has greatly eroded. Official VA reports document the decline. Much less is being spent on care. That 

could be attributed to increased efficiency, were it not for the fact that there has 

been a drastic decline in the unique number of veterans getting specialized substance abuse care. Nor is this due to lack of need. Three networks actually increased 

the number being served, while also becoming more cost efficient. The result is that 

today there are vast discrepancies in access to care across the country. 

Very small improvements can be noted in the past two years as new money has 

been allocated to improve services. Even still, there are examples of medical centers 

taking expansion money for one mental health program while simultaneously cutting substance abuse services. 

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There are many dedicated staff working to provide care, but they are stretched 

and stressed. Many recognize that services need to be expanded and modernized to 

meet the needs of a new cohort of OIF/OEF veterans, but they have no resources 

to do so. 

VA programs often focus on the most severe dependent substance abusers. These 

patients need and deserve much care. 

But the new veteran often needs a different kind of service. He or she may be 

at the beginning of the long drop; binge drinking, getting DUI’s, starting to destroy 

family relationships. In the private sector you will find many comprehensive substance use disorder programs that include a hefty component to provide short term, 

tailored interventions for those at the hazardous or harmful phase of abuse. These 

brief intervention experts coordinate closely with primary care staff, educating 

them, working with them to assure that these patients get effective early care. Such 

programming is alarmingly rare in VA. 

Military and VA studies document the growth of problem gambling. This is especially true for the new veteran. VA was a pioneer in gambling treatment. Yet today 

even few VA substance abuse programs systematically screen for this common comorbidity of substance use. 

I could go on and provide more details but let me end here with a true story. On 

a visit to a reserve unit last year I was approached by a reservist home from his 

second deployment. He was changed. He knew it. His sergeant knew it. His wife 

knew it. He was drinking too much. A patriotic rural judge had let him off from 

his first DUI with a stiff warning. He wasn’t the father or husband he always saw 

himself being. He’d had a rough deployment, but that wasn’t what he wanted to talk 

about. I don’t know if his problems were related to the trauma he witnessed or the 

explosion near him. He wanted to know what he should do. He wanted to do something, though there were many things he worried about in seeking help, including 

his career. I directed him to the VA nearest where he lived. It was not one I had 

visited recently. I hope he found ready immediate access to the services he needed 

at that VA, before he talked himself out of sticking with it. 

Then and now, I am not sure he would. 

The war is now. Men and women like him need the best we can offer in substance 

disorder services, now. We are, based on my ground level view, falling tragically 

short in meeting our responsibility to them. 

I have many thoughts on what should be done. Let me share just one, though a 

big one. VHA needs to immediately improve on the depth of the assessment I can 

provide. They must conduct a comprehensive comparison of each and every VA Medical Center and large outpatient clinic against VA’s own practice guidelines for substance use disorders, including newer modern services for OIF/OEF veterans. This 

assessment should include site visits and confidential, non-attributional, discussion 

and surveys of substance abuse staff. A report detailing all short falls should then 

be used to deploy additional staffing to bridge some of the gap in services that has 

widened over the past 10 years. It should not be local option whether a full array 

of services are provided. VHA is a national system, there should be a national predictable, consistent continuum of care so that any veteran can be assured of ready 

access regardless of where he or she resides. 

I would rejoice if such a comprehensive assessment found that my ground level 

view was in error. 

Addendum on problem gambling as a rising comorbity of substance abuse 

among veterans: 

Scope of the problem: 

Problem gambling is a serious problem that affects veterans and active duty service members and a common complicating comorbitity for other serious conditions. 

It has disastrous consequences for the veteran and his or her family. 

Nationally between 1.6% and 3.4% of the general population have a lifetime probability of experiencing a significant gambling problem. Rates among age matched 

veterans are significantly higher, and highest among minorities. Rates are even 

higher among veterans seeking treatment for some other condition. For example, 

studies have shown: 

• A survey of veterans living in the community found that 9.9% of American Indian veterans and 4.3% of Hispanic veterans had a pathological gambling problem at some point in their lives. 

• Up to one third of veterans in treatment for a substance abuse problem also 

have a significant gambling problem. 

• Veterans in treatment for PTSD may be as much as 60 times more likely to 

have a gambling problem than age matched members of the general population. 

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• Among veterans hospitalized on a VA inpatient psychiatric unit, 28% were classified as problem gamblers and 12% as pathological gamblers. 

Rates of depression among veterans with pathological gambling problems have 

been shown to be as high as 76%. Suicide is extremely common, with 40% of veterans seeking treatment for gambling reporting suicide attempts. 

There is every reason to believe that gambling will continue to be a problem for 

veterans. Rates of gambling have been rising among active duty members, and of 

those seeking treatment for gambling, 42% have considered suicide. This parallels 

increasing concern with financial troubles among military members and their families. 

New studies have suggested that gambling may be an increasing problem for 

older patients being treated for neurological conditions such as Parkinson disease. 

Rates of serious disorders of impulse control, mostly gambling, among patients receiving the most common pharmacological treatments (dopamine agonists) for Parkinson have been measured at 7%, well above the rate expected for age matched 

people in the general population. 

A government commission estimated that the total costs (healthcare, legal, social) 

in the United States attributable to pathological gambling exceed $5 billion. 

Availability of Treatment for Veterans with Gambling Problems 

Specialized treatment programs for veterans with pathological gambling are rare. 

Even though VA was the site of the first intensive national program for pathological 

gamblers, established forty years ago, and responsible for much of the early research on this disorder, the number of specialized programs in VHA is meager. 

Despite overwhelming evidence that pathological gambling is a common and serious complicating comorbidity, veterans seeking mental health or substance abuse 

care in VHA are not generally screened for gambling problems. 

There is substantial evidence that pathological gambling, even in its most serious 

form, can be successfully treated, including among veterans with the disorder. Rates 

of success continue to climb as newer treatment approaches are developed and studied. Economical screening instruments for gambling are available and have been 

shown to be effective in veteran populations. 

Recommended Action 

VHA should significantly increase access for veterans to specialized treatment for 

pathological gambling. Initially at least one program should be established in every 

VHA Network. 

All veterans receiving VHA treatment for substance abuse, PTSD and other mental 

health conditions should routinely be screened for gambling problems, using available standardized screening tools. 

At least one staff member in every VHA substance abuse and PTSD specialized 

treatment program should be trained and competent in treating comorbid gambling 

problems. 

VHA should establish a full-time position as national gambling coordinator within 

the office of the Mental Health Strategic Group. This person would be responsible for 

increasing access to treatment for veterans with gambling problems and assuring 

that veterans at risk for gambling problems are screened and referred to appropriate 

treatment when necessary. 

References 

Biddle D, Hawthorne G, Forbes D, Coman G. Problem Gambling in Australian 

PTSD Treatment Seeking Veterans. Journal of Traumatic Stress, 18, 759–67, 2005. 

Daghestani AI, Elenz E, Crayton JW. Pathological gambling in hospitalized substance abusing veterans. Journal of Clinical Psychiatry, 57(8), 360–63, 1996. 

Gerstein, D.R., Volberg, R.A., Harwood, R., Christiansen, E.M., et al. 1999. Gambling Impact and Behavior Study: Report to the National Gambling Impact Study 

Commission. Chicago, IL: National Opinion Research Center at the University of 

Chicago. Kennedy CH, Jones DE, Grayson R. Substance abuse and gambling treatment in the military. Military Psychology, Clinical and Operational Applications. 

Guilford Press, 2006. 

Kausch O. Suicide Attempts Among Veterans Seeking Treatment for Pathological 

Gambling. Journal of Clinical Psychiatry, 64(9) 1031–1038, 2003. 

Kim SW, Grant JE, Eckert D et al. Pathological gambling and mood disorders. 

Journal of Affective Disorders. 92, 109–116, 2006. 

McCormick RA, Russo A, Ramirez L, Taber JI. Affective disorders among pathological gamblers. American Journal of Psychiatry, 141, 215–18, 1984. 

Miller MA & Westermeyer J. Gambling in Minnesota. American Journal of Psychiatry, 135(6), 845, 1996. 

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1 Bray, R., Hourani, L., Olmstead, K., et al (2006, August). 2005 Department of Defense Survey of Health Related Behaviors Among Active Duty Military Personnel: A Component of the 

Defense Lifestyle Assessment Program (DLAP). NC: Research Triangle Institute. 2 An Achievable Vision: The Report of the Department of Defense Mental Health Task Force, 

June 2007. 3 Ibid. 

4Wheeler, E. Self Reported Mental Health Status and Needs of Iraq Veterans in the Maine 

Army National Guard. Community Counseling Center, 2007 (unpublished). 5 An Achievable Vision: The Report of the Department of Defense Mental Health Task Force, 

June 2007. 6 Robert Davis and Gregg Zoroya, ‘‘Study: Child abuse, troop deployment linked,’’ USA Today, 

7 May 2007: http://www.usatoday.com/news/nation/2007-05-07-troops-child-abuse_N.htm 

Pallesen S, Mitsem M, Kvale G, et al. Outcome of psychological treatments of 

pathological gambling: A review and meta-analysis. Addiction, 100, 1412–22, 2005. 

Taber JI, McCormick RA, Russo, A et al. Follow-up of pathological gamblers after 

treatment. American Journal of Psychiatry, 144, 7575–61, 1987. 

Weintraub D, Siderowf AD, Potenza MN, et al. The Association of Dopamine 

Agonist Use with Impulse Control Disorders In Parkinson Disease, Archives of Neurology, 63(7), 969–973, 2006. 

Westermeyer J, Canive J, Garrard J et al. Lifetime prevalence of pathological 

gambling among American Indian and Hispanic American Veterans. American Journal of Public Health, 95(5), 860–6, 2005. 

f 

Prepared Statement of Joy J. Ilem 

Assistant National Legislative Director, Disabled American Veterans 

Mr. Chairman and Members of the Subcommittee: 

Thank you for inviting the Disabled American Veterans (DAV), an organization 

of 1.3 million service-disabled veterans, to testify at this important hearing to discuss solutions for veterans dealing with substance use disorders and co-existing 

mental health conditions. We appreciate the opportunity to offer our views on Department of Veterans Affairs (VA) specialized programs for these conditions. 

The misuse and abuse of alcohol and other substances continues to be a major 

health problem for many Americans, including many of our Nation’s veterans. Substance use disorders result in significant health and social deterioration and financial costs to veterans, their families and the nation. Although substance abuse is 

a complex problem, there is clear evidence that treatments can be brought to bear 

to reduce these negative consequences. 

The Scope of the Substance Use and Abuse Problem is Growing: 

DAV has a growing concern about the reported effects of combat deployments in 

Iraq and Afghanistan on our newest generation of war veterans. There is converging 

evidence that substance abuse is a significant problem for many veterans of Operations Iraqi and Enduring Freedom (OIF/OEF)—and that the incidence of this problem will likely continue to rise. Over the past year there have been a number of 

research and media reports highlighting the prevalence of substance use and other 

mental health problems among OIF/OEF veterans and the challenges that many of 

these veterans and their families are facing post-deployment. Among the most notable are—— 

• In the most recent Department of Defense (DoD) anonymous Survey of Health 

Related Behaviors Among Active Duty Personnel, 23% acknowledge a significant alcohol problem;1

• Alcohol related incidents (e.g. DUI, drunk and disorderly) reported in the Army 

Forces Command data base increased from 1.73 per 1,000 soldiers in 2005, to 

5.71 in 2006;2

• Alcohol contributed to 65% of the markedly increased incidence of suicidal behavior in the military;3

• In a recent study of returning National Guard, 24% reported alcohol abuse;4

• Reported rates of psychological problems increase with multiple deployments;5

and, 

• Reports of child abuse and increased incidence of marital problems in military 

families as a result of multiple deployments.6

Current research also highlights that OIF/OEF veterans are at higher risk for 

post traumatic stress disorder (PTSD) and other mental health problems as a result 

of combat exposure. VA reports that these veterans have sought care for a wide 

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51 

7Department of Veterans Affairs, VHA Office of Public Health and Environmental Hazards, 

‘‘Analysis of VA Health Care Utilization Among US Global War on Terrorism (GWOT) Veterans: 

Operation Enduring Freedom, Operation Iraqi Freedom,’’ January 2008. 8Kline, A., Falca-Dodson, M. Substance Abuse and Mental Health Problems in Returning 

Iraqi Veterans. VA New Jersey Healthcare System and New Jersey Department of Military and 

Veterans Affairs, 2007. (unpublished) 9Wheeler, E. Self Reported Mental Health Status and Needs of Iraq Veterans in the Maine 

Army National Guard. Community Counseling Center, 2007 (unpublished). 10 Bray, R., Hourani, L., Olmstead, K., et al. (2006, August). 2005 Department of Defense Survey of Health Related Behaviors Among Active Duty Military Personnel: A Component of the 

Defense Lifestyle Assessment Program (DLAP). NC: Research Triangle Institute. 

array of possible co-morbid medical and psychological conditions, including adjustment disorder, anxiety, depression, PTSD, and the effects of substance abuse. 

Through January 2008, VA has reported that of the 299,585 separated OIF/OEF 

veterans who have sought VA healthcare since fiscal year 2002, a total of 120,049 

unique patients had received a diagnosis of a possible mental health disorder. Almost 60,000 enrolled OIF/OEF veterans had a probable diagnosis of PTSD; almost 

40,000 OIF/OEF veterans have been diagnosed with depression; and, more than 

48,000 reported nondependent abuse of drugs.7 These data are consistent with DoD 

studies of active duty OIF combat troops. 

In a recent study, VA New Jersey-based researchers examined substance abuse 

and mental health problems in returning veterans of the war in Iraq. Researchers 

noted that although increasing attention is being paid to combat stress disorders in 

veterans, there has been little systemic focus on substance abuse problems in this 

population. Among the 292 National Guard members studied, an alarmingly high 

percentage (39 percent) reported one or more substance abuse-related problems. 

Rates were even higher among the subset who were youngest (e.g., ‘‘problem drinking’’ in 46 percent) and had high exposure to combat (e.g., 52 percent reported problem drinking). Yet access to substance abuse services for the group studied was very 

low (only 9 percent), compared with access to other mental health services (41 percent).8

Similarly, a study of returning Maine National Guard members found substance 

abuse problems in 24 percent of the troops surveyed.9 In the most recent DoD anonymous Survey of Health Related Behaviors Among Active Duty Personnel, 23 percent 

of respondents acknowledged a significant alcohol problem.10

Lack of Seamless Detoxification-to-Rehabilitation Transition Services: 

We have special concerns about VA’s local policies on making detoxification services readily and widely available to veteran candidates who are interested in substance abuse rehabilitation services. VA officials have informed us that detoxification services provided by internal medicine bed sections should be readily available 

within all VA medical centers to veterans who need them as a precursor to admission to VA substance use disorder treatment programs. Physical detoxification, 

whether from dependent alcohol or other drug use, is the essential key in preparing 

a veteran for therapeutic rehabilitation and sobriety. However, we understand that, 

in many cases, VA’s substance abuse treatment programs will not accept a veteran 

who is actively drinking or using drugs. We have received anecdotal stories from 

VA sources in field facilities to indicate that often, intoxicated veterans who come 

to VA for care are instead turned away, and occasionally they are even arrested for 

public drunkenness or property violations. We strongly believe that having a substance use disorder should not be a barrier to receiving care for that condition or 

entrance into any other VA specialized treatment program. 

Current and former VA clinicians with expertise in substance use disorder treatment have informed us that VA medical centers with robust substance use treatment programs generally have clinical staff that maintain a close liaison with VA 

admitting offices, emergency rooms, internal medicine, and primary care clinics, for 

the purpose of identifying veterans who need detoxification services. When these patients are identified, liaison staff members ensure they receive proper referral to detoxification resources in internal medicine and then help these veterans make their 

transition to follow-on substance abuse treatment programs. In medical centers 

without fully integrated substance abuse services, patients may not be identified or 

properly referred, and even if they are detoxified, they might fall through the 

cracks, or refuse this critically important specialized follow on care, thus wasting 

significant healthcare resources and ultimately failing these veterans. 

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11Department of Veterans Affairs National Mental Health Program Performance Monitoring 

System, Fiscal Year 2006. 

12 An Achievable Vision: The Report of the Department of Defense Mental Health Task Force, 

June 2007. 

13Department of Veterans Affairs National Mental Health Program Performance Monitoring 

System, Fiscal Year 2006 Report. 

14 United States Department of Veterans Affairs, Overview of Homelessness, March 6, 2008. 

http://www1.va.gov/homeless/page.cfm?pg=1. 

Inadequacy of Substance Disorders and Co-Morbid Mental Health Treatments in VA 

The past decade has been marked by unparalleled growth in VA clinical services. 

Unfortunately, substance use treatment and rehabilitation resources have declined 

during that same period and VA has made little progress in restoring them, even 

in the face of likely increased demand from veterans returning from OIF/OEF. In 

1996 specialized substance abuse treatment services accounted for 3.8 percent of 

VA’s clinical budget—but by 2006, this fraction had dropped to 1.8 percent. A number of national population surveys of the prevalence of substance abuse show no 

comparable decline in incidence of drug and alcohol addiction. Over the same period 

(1996 to 2006) the number of veterans receiving specialized substance abuse treatment services declined by approximately 18 percent, with the exception of a slight 

growth (2 percent) from 2005 to 2006, due to infusion of specifically directed supplemental funding. Furthermore, there has been a marked increase in the variability 

of access to a comprehensive continuum of care for substance abuse services. In 

2006 (latest data available to DAV), VA’s Veterans Health Administration (VHA) 

networks varied markedly in the proportion of their patient populations that were 

treated in substance abuse specialty care. The normalized rates for veterans treated 

for substance abuse ranged from 8.5 per 1,000 treated for any condition to 3.3 per 

1,000.11 Experts in this field have informed DAV that this variability cannot be explained by regional differences in the prevalence of substance abuse disorders. Finally, although it is known that many mental health conditions including PTSD, 

anxiety disorders and depression are frequently associated with substance use disorders, currently there are few integrated treatment programs available in VA to 

address these co-existing disorders. 

Given the need we see for these specialized services not only in the older veteran 

population cohorts but especially in the latest generation of war veterans, these 

findings are of great concern to the DAV. 

The Relationship Between Substance Use Disorders and Other Major Medical and Mental Health Conditions 

According to experts and published literature, substance use disorders are common co-morbidities with other medical and mental health conditions. Some significant examples include— 

• Veterans with PTSD often use alcohol or other drugs to blunt memory, escape 

pain and self-medicate for stress. In recognition of this tendency, VA’s evidencebased treatment guidelines for PTSD generally require that veterans in treatment for PTSD also receive screening and treatment for substance use disorders. 

• Abuse of substances is a significant risk factor in suicidal ideation.12

• Literature indicates that up to 50 percent of veterans with severe mental illnesses (e.g. schizophrenia, bipolar disorder) also have a substance use problem.13

• The most common means of contracting Hepatitis C (a condition notably higher 

in the veteran population than the general population), and other serious liver 

diseases, is through injection of illicit drugs. Furthermore, the most effective 

treatments for Hepatitis C require that the patient not be currently abusing alcohol or other drugs before treatment can commence. 

• Excessive use of alcohol or other drugs complicates the treatment of diabetes, 

cardiac disorders and other major medical diseases and conditions. 

• VA reports that approximately 70 percent of homeless veterans receiving services from VA suffer from alcohol or drug abuse problems.14

Conclusions 

All the foregoing research, surveys, reports and experience validate that substance use disorders are prevalent among veterans, particularly younger veterans 

and those who have experienced combat or other significant trauma. Therefore, it 

is likely that OIF/OEF veterans will significantly increase demand for specialty subwwoods2 on PRODPC68 with HEARING

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stance abuse treatment services in VA. Unfortunately, many veterans, including 

younger OIF/OEF veterans, with substance use disorders do not have access to an 

array of comprehensive treatments across the VA healthcare system. Lack of access 

to such services will likely result in sub-optimal rehabilitation for thousands of veterans, including many with severe medical and mental health co-morbid conditions 

that require concurrent treatment of their alcohol and drug abuse disorders. Untreated substance abuse can result in severe physical consequences for the veteran, 

stress on the family, and marked increase in medical and social costs including loss 

of employment and in some cases, serious legal difficulties. 

VA Policies and Treatment Programs Need Further Adaption 

VA and DoD evidence-based treatment guidelines for substance use disorders document the substantial research supporting effectiveness of a variety of treatments. 

Based on these guidelines, we believe veterans should have access to a full continuum of care for substance use disorders including: screening in all care locations, 

particularly in primary care; short term outpatient counseling including motivational intervention; ongoing aftercare and outpatient counseling; intensive outpatient treatment; residential care for the most severely addicted; widely available 

detoxification and stabilization services; ongoing aftercare and relapse prevention; 

self-help groups; and, opiate substitution therapy and other pharmacological treatments, including access to newer drugs to reduce cravings. 

Additionally, VA must continue to educate its primary care providers about, and 

fully implement these guidelines, including better detection of substance use disorders in veterans under VA care, to ensure that problems are identified early and 

that patients are referred for appropriate treatment. Substance use—common as a 

secondary diagnosis among newly injured veterans and others with chronic illness 

or injury—can often be overshadowed by acute care needs that may seem more compelling. Therefore, we urge VA and DoD to continue research into this critical area 

and to identify the best treatment strategies to address substance use disorders and 

other mental health and readjustment issues collectively. 

A final concern we have is VA’s practical policy to serve as a seemingly ‘‘rock bottom’’ program in substance abuse treatment and rehabilitation. It appears that VA’s 

main focus in providing substance abuse treatment is to serve a population that has 

not abated their substance misuse and consequently have deteriorated to a point of 

social or medical disfunctionality. While we applaud VA’s efforts to save individuals 

from the misery of chronic addiction, we are concerned about the locus of this program because of reports that ‘‘hazardous’’ and ‘‘non-dependent’’ use of drugs and alcohol in seemingly functional OIF/OEF veterans is significant. We believe VA’s focus 

on the most severe dependent substance abusers to the exclusion of this newer generation of problem drinkers and occasional pre-dependent drug users will cause 

many newer combat veterans additional misery and decline that could be avoidable. 

We urge VA to revamp its programs to focus on earlier interventions in individuals’ 

misuse of substances. 

Recommended Legislative Action 

With these views in mind, DAV recommends the Subcommittee advance legislation that— 

• Mandates VA provide a full continuum of care for veterans with substance use 

disorders equitably across the country. These services should be available at all 

medical centers with outpatient counseling and pharmacotherapy available at 

all larger community based outpatient clinics. Residential substance abuse 

treatment should be readily available for those requiring a higher level of care 

in each network. Brief motivational interventions, particularly for hazardous 

drinkers, should be offered in primary care settings whenever possible. Additionally, VA should employ peer counselors for outreach to OIF/OEF veterans 

struggling with substance use problems. 

• Allocates adequate funding to assure that this full continuum of substance use 

disorder care is provided, on an equitable basis, for all veterans who need it. 

• Requires an annual update on the progress in providing equitable access to a 

full continuum of substance abuse care. This report should include meaningful 

data on the number of veterans provided specialty substance use disorder care; 

the results of universal screening for substance abuse in primary care; and, a 

measurement of the availability of services at each facility and in each network 

as specified by VA’s adopted national clinical practice guidelines for substance 

use disorder care. 

• Authorizes a pilot program specifically designed to offer web-based options for 

substance use treatment and group support targeted at OIF/OEF veterans who 

reside in rural or remote areas. 

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• Provides specifically designated funding for research projects to identify the best 

treatment strategies and practices to collectively address substance use disorders and other co-morbid mental health readjustment issues. 

Closing 

Mr. Chairman, the current overseas deployments to combat theaters in Iraq and 

Afghanistan (and other Global War on Terror deployments) are resulting in not only 

serious physical injuries to veterans but heavy casualties in what are considered the 

‘‘invisible’’ wounds of war: PTSD, depression, family disruptions and divorce, hazardous drinking and drug use, and a number of other social and emotional consequences for those who have served. DoD, VA and Congress must remain vigilant 

to ensure that federal programs aimed at meeting the extraordinary needs of disabled veterans are sufficiently funded and adapted to meet them, while continuing 

to address the chronic health maintenance needs of older disabled veterans who 

served in earlier military conflicts. Also, Congress must remain apprised about how 

VA spends the significant new funds that have been added and earmarked for the 

purpose of meeting post-deployment mental healthcare and physical rehabilitation 

needs of veterans who served in OIF/OEF. 

DoD and VA share a unique obligation to meet the healthcare and rehabilitative 

needs of combat veterans who have been wounded or who may be suffering from 

severe readjustment difficulties as a result of combat and hardship deployments. We 

owe our Nation’s disabled veterans access to timely and appropriate healthcare services including specialized substance use treatment programs for those suffering with 

both mental health and substance use disorders. We must ensure that VA establishes and sufficiently funds effective programs now aimed at prevention, early 

intervention, outreach and education and training for veterans and their families to 

close the current gaps that exist. Finally, as we indicated earlier in this statement, 

DAV believes that having a substance use disorder should not be a barrier to receiving care for that condition or entrance into any other VA specialized treatment program. We deeply appreciate that the Subcommittee is addressing these issues with 

both oversight and legislation when appropriate. To that end, we note and thank 

the Chairman and Ranking Member for jointly introducing the ‘‘Veterans Substance 

Use Disorders Prevention and Treatment Act of 2008,’’ an Act that would accomplish many of the goals we have identified in this testimony, to address substance 

use disorders in the veteran population. 

Mr. Chairman, this concludes my statement, and I will be pleased to respond to 

any questions you may wish to ask with regard to these issues. 

f 

Prepared Statement of Thomas J. Berger, Ph.D., 

Chair, National PTSD and Substance Abuse Committee, Vietnam Veterans 

of America 

Mr. Chairman, Ranking Member Miller, distinguished members of this Subcommittee, and guests, Vietnam Veterans of America (VVA) thanks you for the opportunity to present our views on substance abuse and co-morbid disorders. Foremost, Vietnam Veterans of America thanks this Subcommittee for your leadership 

in holding this hearing today on a most serious concern within our veterans’ community. 

Each month hundreds of active duty troops, reservists and National Guard members return to their families and communities from deployment in Iraq and Afghanistan. Given the demanding and traumatizing environments of their combat experiences, many veterans experience psychological stresses that are further complicated 

by substance use and related disorders. In fact, research studies indicate that veterans in the general U.S. population are at increased risk of suicide. 

Moreover, according to the results of a national Survey on Drug Use and Health 

report issued by SAMHSA in November 2007, among veterans of the wars in Iraq 

and Afghanistan who received care from the Department of Veterans Affairs between 2001 and 2005, nearly one-third were diagnosed with mental health and/or 

psychosocial problems and one-fifth were diagnosed with a substance use disorder 

(SUD). Substance dependence or abuse includes such symptoms as withdrawal, tolerance, use in dangerous situations, trouble with the law, and interference in major 

obligations at work, school, or home during the past year. Individuals who meet the 

criteria for either dependence or abuse are said to have a SUD. 

In this NSDUH report, combined data from 2004 to 2006 indicate that an annual 

average of 7.0 percent of veterans aged 18 or older (an estimated 1.8 million persons 

annually) experienced serious psychological distress (SPD) in the past year. Veterans aged 18 to 25 were more likely to have had an SPD (20.9 percent) than vetwwoods2 on PRODPC68 with HEARING

55 

erans aged 26 to 54 (11.2 percent) or those aged 55 or older (4.3 percent). Female 

veterans were twice as likely as male veterans to have had an SPD in the past year 

(14.5 vs. 6.5 percent). And veterans with family incomes of less than $20,000 per 

year were more likely to have had an SPD in the past year than veterans with higher family incomes. 

Substance Use Disorders 

The combined data from 2004 to 2006 also indicate that an annual average of 7.1 

percent of veterans aged 18 or older (an estimated 1.8 million persons) met the criteria for a SUD in the past year. One-quarter of veterans aged 18 to 25 met the 

criteria for a SUD in the past year compared with 11.3 percent of veterans aged 

26 to 54 and 4.4 percent of veterans aged 55 or older. There was no difference in 

SUD between male and female veterans (7.2 vs. 5.8 percent). And veterans with a 

family income of less than $20,000 per year (10.8 percent) were more likely to have 

met the criteria for a SUD in the past year than veterans with a family income of 

$20,000 to $49,999 (6.6 percent), $50,000 to $74,999 (6.3 percent), or $75,000 or 

more (6.7 percent). 

Co-occurring Disorders 

From 2004 to 2006, approximately 1.5 percent of veterans aged 18 or older (an 

estimated 395,000 persons) had a co-occurring SPD and SUD. Increasing age was 

associated with lower rates of past year co-occurring SPD and SUD, with veterans 

aged 18 to 25 having the highest rate (8.4 percent) and veterans aged 55 or older 

having the lowest rate (0.7 percent). There was no significant difference in co-occurring disorders among males and females (1.5 vs. 2.0 percent, respectively). And veterans with family incomes of less than $20,000 per year were more likely to have 

had a co-occurring SPD and SUD in the past year than veterans with higher family 

incomes. 

These data can be summarized briefly below— 

Combined data from 2004 to 2006 indicate that an annual average of 7.0 percent 

of veterans aged 18 or older experienced past year serious psychological distress 

(SPD), 7.1 percent met the criteria for a past year substance use disorder (SUD), 

and 1.5 percent had co-occurring SPD and SUD. 

Veterans aged 18 to 25 were more likely than older veterans to have higher rates 

of past year SPD, SUD, and co-occurring SPD and SUD. Veterans with family incomes of less than $20,000 per year were more likely than veterans with higher 

family incomes to have had SPD, SUD, and co-occurring SPD and SUD in the past 

year. 

And we must remember these data represent only those veterans who chose to 

seek help for their disorders from the VA. Vietnam Veterans of America has no reason to believe that the numbers cited above would not be higher if more of our OEF 

and OIF veterans were to seek VA care. 

The medical, social, and psychological toll from substance abuse disorders is enormous, both for the military and civilian sectors. In the face of such overwhelming 

damage, two questions emerge: Why does substance abuse receive relatively little 

medical and public health attention and support compared with other medical conditions? And what can be done to reduce the harm from substance abuse disorders? 

Despite their huge health toll, substance abuse disorders remain underappreciated and under-funded. Reasons include stigma, tolerance of personal choices, acceptance of youthful experimentation, pessimism about treatment efficacy, fragmented and weak leadership, powerful tobacco and alcohol industries, underinvestment in research, and difficult patients. 

Stigma: Despite emerging scientific evidence that substance abuse alters 

neurotransmitter patterns, many still stigmatize smokers, alcoholics, and drug abusers for having made unwise choices. They feel that even if central nervous system 

changes result from substance abuse, the choices were wrong in the first place. Another factor is the popular (and spurious) association of substance abuse with minorities. All too often, substance abuse is seen as having a black face, even though 

differences between blacks and whites in the prevalence of smoking and alcoholism 

and drug abuse do not support such stereotyping. Finally, public exposure to substance abuse can be polarizing, whether through secondhand smoke, raucous 

drunks, endangerment by an intoxicated driver, or encounters with aggressive alcoholic or drug-abusing homeless persons. 

Civil liberties/free choice: A strong theme of U.S. culture is respect for choice 

and individual freedom. When the public health evidence is sufficiently compelling— 

such as with secondhand smoke or drunk-driving fatalities—regulatory measures 

can trump that civil libertarian tilt, but usually only after a long struggle. 

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Tolerance of youthful experimentation: Most adults experimented in their 

youth with tobacco, alcohol, and drugs, and most drink responsibly as adults. They 

view these experiences as developmental rites of passage and may be unsympathetic 

to the minority who become addicted. 

Futility/hopelessness: The problems of substance abuse have been around so 

long that they seem to be intractable. In reality, there has been slow but impressive 

progress. U.S. smoking rates have declined since 2000, youth smoking is lessening, 

alcohol-related motor vehicle fatalities have fallen despite major increases in miles 

traveled, and the prevalence of illicit drug use has fallen. 

Pessimism about treatment efficacy: Public officials and clinicians share a double standard about treating substance abuse. Although they embrace aggressive 

treatment for diseases with miserable prognoses (for example, pancreatic cancer and 

malignant melanomas), they are skeptical about funding substance abuse treatment 

in which rates of one-year remissions may vary for smoking and for alcoholism and 

drug abuse. In clinical settings, this attitude is reinforced by clinicians’ natural reluctance to encounter failures—smokers and drinkers who will not or cannot quit. 

One reason for this double standard is that substance abuse disorders are seen as 

volitional, while aggressive cancers are not. And recent data show declines in receipt 

of substance abuse treatment under private health insurance. 

Leadership: In contrast to breast cancer or HIV/AIDS, there are no aroused citizen advocacy groups for substance abuse disorders. The important exceptions of 

Mothers Against Drunk Driving and Students Against Drunk Driving and DARE 

stand as lone outliers to this rule. Undoubtedly, stigma makes it difficult for concerned groups to coalesce for public action. Even the most successful citizens group, 

Alcoholics Anonymous (AA), works undercover by design. Thus, there is no national 

‘‘race for the cure’’ against smoking-induced lung cancer and no national mobilized 

women’s group fighting to stop alcoholism, smoking, or drug abuse. 

Fragmentation in the substance abuse field: Not only is there failure to coalesce among the three categories of substances, but even within each class there is 

rivalry, such as tensions between those who advocate for a twelve-step approach to 

drug and alcohol treatment and those who promote pharmaceutical treatment. 

Industries’ power: The tobacco and alcohol industries spend billions on advertising and promotion, not to mention their contributions to political campaigns. 

These industries exert powerful political influence and have a track record of successful opposition to programs that would reduce use of their products. Investigators 

working to reduce harm from tobacco have been subjected to legal harassment, including suits requiring submission of voluminous primary data, depositions, and 

court testimony. 

Underinvestment in research: Despite the huge toll exerted by tobacco, only a 

small percent of the National Institutes of Health (NIH) budget is devoted to tobacco research. Similarly, the combined budgets of the National Institute on Drug 

Abuse (NIDA) and the National Institute on Alcohol Abuse and Alcoholism (NIAAA) 

amounted to $1.38 billion in 2003, or less than 5 percent of total NIH expenditures. 

Difficult patients: Clinicians find it hard to care for patients with substance 

abuse problems. This reflects the limited education and training most clinicians receive on this topic and disappointment that so few patients follow their advice about 

quitting. At least in the case of drug-seeking behavior (when patients seek narcotics 

from physicians), the doctors may stop trusting these patients. 

Despite the obstacles noted above, VVA believes that a coordinated workable 

agenda within the military and the civilian population is possible to lessen the impact of substance use disorders. But this coordinated agenda must include the following— 

Better approaches to treatment: Adequate treatment for substance abuse is 

particularly challenging for America’s uninsured. Even for the insured, many policies, including most Medicaid programs, do not cover the time for counseling or the 

costs of drugs such as nicotine replacement therapy and bupropion for smoking cessation, methadone for drug addiction, or disulfiram for alcoholism. 

As new, effective drugs come on the market, patients must have access to them. 

Clinicians and policymakers need to reframe how ‘‘successful treatment’’ is defined. 

Physicians caring for patients with asthma or diabetes understand that these are 

chronic illnesses and that the goal is to maximize functioning and minimize disability. By contrast, many clinicians become frustrated because it is difficult to 

‘‘cure’’ smokers, alcoholics, or drug abusers. Rather than acknowledging that patterns of use often follow a waxing and waning course, that a year of sobriety is 

cause for triumph and social good, and that it may take many attempts before a 

patient is able to quit, they too often see the glass as half empty. Envisioning the 

goal of substance abuse treatment as managing chronic illness—including knowing 

appropriate referral sources within the community and the roles of non-physician 

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professionals—could help doctors celebrate the tangible benefits of such treatment, 

instead of lamenting the reality that cures for most chronic diseases are often elusive. Drug courts, which offer treatment as an alternative to incarceration, are a 

promising but greatly underused resource. 

More support for research: Devote 20 percent of the current NIH budget to substance abuse research rather than the current amount. Beyond studying the basic 

science of addiction and exploring new pharmacologic treatments, research could 

help us understand why some people who experiment with substances become addicted while others do not, the comparative efficacy of different modes of treatment, 

the complexities of dual diagnosis (co-occurring mental illness and substance abuse), 

the social context of addiction, and the impact of various social policies on addiction 

and the harm it causes. 

Better education of health professionals: Substance abuse receives minimal 

notice in undergraduate and graduate medical education, specialty board certifying 

exams, continuing medical education, standard clinical textbooks, and medical journals. Not only is content slighted, but it is rare for medical education to acknowledge the role of other health professionals in treating substance abuse or the workings of twelve-step programs such as AA. This relative under-emphasis reflects the 

reality that few medical faculty work in the area of substance abuse. The neglect 

is disappointing, given the extent to which substance abuse accounts for illness in 

Veterans Affairs (VA) and county hospitals—sites of intensive medical education for 

most academic medical centers. 

Nongovernmental funding: Although government will continue to provide the 

bulk of substance abuse treatment and research dollars, there are gaps in its funding. Some interventions—such as needle exchanges for heroin addicts as a way to 

reduce the transmission of HIV and hepatitis—may challenge strongly held ideological views, thus precluding government support. Also, the power of the tobacco and 

alcohol industries may deter adoption of proven public health strategies such as 

raising cigarette taxes or lowering the permissible blood alcohol level for drivers. Because there are areas where government either will not or cannot take a stand, private support matters. Examples are the role of the ACS and the Robert Wood Johnson Foundation in establishing the CTFK, the counter-marketing of the American 

Legacy Foundation and the Partnership for a Drug-Free America, and the Conrad 

N. Hilton Foundation’s support for substance abuse educational programs in public 

schools. 

Stronger leadership needed: Greater recognition of substance abuse as a major 

health problem should encourage broader and more diverse leadership. Whether 

that leadership can or should transcend the individual substance categories is not 

clear. It may be that lumping together marijuana, beer, cigarettes, and heroin is too 

unwieldy to generate a unified constituency. Although substance abuse affects women’s health, it has yet to surface on the advocacy agenda of the many women’s organizations. 

Drug policies: Providing adequate treatment for community-based and incarcerated people with drug addiction generates social and medical savings: lower crime, 

lower prison spending, less family dysfunction, and better health. A RAND report 

of mandatory minimum sentences for cocaine concluded that dollar for dollar, treatment is fifteen times more effective than incarceration in reducing serious crime. 

Another study showed that treatment for substance abuse in criminal justice settings lowers re-incarceration rates. Also, providing clean needles for heroin addicts 

reduces the transmission of blood-borne diseases. 

Reform of the criminal justice system for substance abuse: Federal and state 

legislation imposes mandatory terms for possession of illicit drugs, thereby removing 

sentencing discretion from the hands of judges. Greater flexibility would reduce the 

cost and burden of incarceration and give many a chance for rehabilitation. Despite 

evidence that providing treatment and drug testing instead of incarceration can reduce both penal and social costs and increase the rate of drug rehabilitation, these 

approaches remain rare. Expansion will require permissive laws and knowledgeable 

judges. State corrections officials estimate that 70–85 percent of inmates need some 

level of substance abuse treatment. But in approximately 7,600 correctional facilities surveyed in 1997, less than 11 percent of the inmates were in drug treatment 

programs. Requiring substance abuse treatment as a condition of parole has been 

shown to increase treatment as well as abstinence from drug use. 

Substance abuse remains a serious medical, public health, and social problem. Yet 

it lacks champions, is underfunded, and is relatively neglected by clinicians and the 

medical establishment. Despite some real progress in the past decade, the United 

States still lags behind virtually every developed country in measures of health status. Our current national strategy to close that gap involves funding biomedical research to yield new treatments and improving access to care for 

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Everyone, including America’s veterans. Both are worthwhile goals but are 

doomed to failure unless they are coupled with effective policies to reduce harm 

from substance abuse. 

Thank you again for the opportunity to offer our views on this issue and I shall 

be glad to answer any questions. 

f 

Prepared Statement of Todd Bowers 

Director of Government Affairs, Iraq and Afghanistan Veterans of America 

Mr. Chairman, ranking member and distinguished members of the committee, on 

behalf of Iraq and Afghanistan Veterans of America, and our tens of thousands of 

members nationwide, I thank you for the opportunity to testify today regarding veterans’ substance abuse. 

In particular, I would like to thank the committee for recognizing the issue of comorbidity. As the committee knows, among the hundreds of thousands of troops returning from Iraq and Afghanistan with a mental health injury, a small but significant percentage is turning to alcohol or drugs in an effort to self-medicate. Veterans’ 

substance abuse problems, therefore, cannot and should not be viewed as distinct 

from mental health problems. 

According to the VA Special Committee on PTSD, at least 30 to 40% of Iraq veterans, or about half a million people, will face a serious psychological injury, including depression, anxiety, or Post Traumatic Stress Disorder or PTSD. Data from the 

military’s own Mental Health Advisory Team shows that multiple tours and inadequate time at home between deployments increase rates of combat stress by 50%. 

We are already seeing the impact of these untreated mental health problems. Between 2005 and 2006, the Army saw an almost threefold increase in ‘‘alcohol-related 

incidents,’’ according to the DOD Task Force on Mental Health. The VA has reported diagnosing more than 48,000 Iraq and Afghanistan veterans with drug 

abuse. That’s 16% of all Iraq and Afghanistan veteran patients at the VA. These 

numbers are only the tip of the iceberg; many veterans do not turn to the VA for 

help coping with substance abuse, instead relying on private programs or avoiding 

treatment altogether. 

Effective diagnosis and treatment of substance abuse is a key component of 

IAVA’s 2008 Legislative Agenda. First and foremost, IAVA supports mandatory and 

confidential mental health screening by a mental health professional for all troops, 

both before and at least 90 days after a combat tour. Moreover, the VA must be 

authorized to bolster their mental health workforce in hospitals, clinics, and Vet 

Centers with adequate psychiatrists, psychologists and social workers to meet the 

demands of returning Iraq and Afghanistan veterans. 

The shortage of mental health professionals in the VA is hampering the effectiveness of mental health and substance abuse treatment. A VA Deputy Undersecretary 

has admitted that waiting lists render mental health and substance abuse care ‘‘virtually inaccessible’’ at some clinics. In October 2006, almost one-third of Vet Centers 

admitted they needed more staff. By April 2007, more than half of the 200-plus Vet 

Centers needed at least one more psychologist or therapist. As a result of the staffing shortage, veterans seeking mental health care get about one-third fewer visits 

with VA specialists now, compared to ten years ago. Veterans in rural communities 

are especially hard-hit. For instance, Montana ranks fourth in sending troops to 

war, but the state’s VA facilities provide the lowest frequency of mental health visits. 

Effective treatment of veterans’ mental health and substance abuse issues requires the real commitment of the Congress to fund an expansion of the corps of 

VA mental health professionals. But improving veterans’ mental health care is not 

simply a legislative fix. That is why IAVA has partnered with the Ad Council, the 

nonprofit organization responsible for some of America’s most effective and memorable public service campaigns, including ‘‘A Mind is a Terrible Thing to Waste,’’ 

‘‘Only You Can Prevent Forest Fires,’’ and ‘‘Friends Don’t Let Friends Drive Drunk.’’ 

This summer, the Ad Council and IAVA will launch a multi-year campaign to destigmatize mental health care for service members and their families. The broadcast, print, web and outdoor ads will encourage those who need it to seek mental 

health care and inform all Americans that seeking help is a sign of strength rather 

than weakness. We are very excited to partner with Ad Council to help get troops, 

veterans, and their families the care they need and deserve. 

I thank you for providing me the opportunity to testify before you this afternoon. 

I would like to point out that my testimony today does not reflect the views of the 

United States Marine Corps. I am here testifying today in my civilian capacity as 

the Director of Government Affairs for Iraq and Afghanistan Veterans of America. 

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All the data and IAVA recommendations I have cited are available in our Mental 

Health report and our Legislative Agenda. It would be my pleasure to answer any 

questions you may have for me at this time. 

Respectfully submitted. 

f 

Prepared Statement of Antonette Zeiss, Ph.D., 

Deputy Chief Consultant, Office of Mental Health Services, Veterans Health 

Administration, U.S. Department of Veterans Affairs 

Mr. Chairman and members of the Subcommittee, I am pleased to be here today 

to discuss the ongoing steps that the Department of Veterans Affairs (VA) is taking 

to treat substance abuse and co-morbid disorders. I am accompanied by Mr. Charles 

Flora, Associate Director of Readjustment Counseling Service. Mr. Flora is a clinical 

social worker and Vietnam veteran, and has a lifetime of experience in readjustment 

counseling at both the Vet Center and national levels. 

Also accompanying me is Dr. John Allen, Associate Chief Consultant for Addictive 

Disorders. Dr. Allen is a national expert on substance use disorders and is a veteran 

of Operation Iraqi Freedom. His commitment to this work goes beyond the call of 

a doctor-patient relationship and echoes the pledge our service members make to 

one another. While VA has always taken the problem of substance use disorder 

(SUD) very seriously and has demonstrated our commitment to helping our veterans 

overcome this disease, we welcome Dr. Allen’s personal connection to our returning 

veterans. 

We thank the Committee and you, Chairman Michaud, for your active interest in 

this topic. Tragically, substance use disorders are common in our society, as they 

are in many societies. As all of you know, the incidence of substance use among veterans tends to exceed that of comparable civilian populations. One study by Todd 

Wagner, et al. from 2007 found veterans are more likely than non-veterans to report 

driving under the influence of alcohol, smoking daily, and using marijuana. In another study, by Dr. Charles Hoge and published in the New England Journal of 

Medicine in 2004, the number of respondents who admitted to using alcohol more 

than they intended increased seven percent among Army respondents after deployment to Iraq or Afghanistan. Alcohol and drug misuse are associated with a host 

of medical, social, mental health, and employment problems. Fortunately, these 

problems are treatable, and with treatment, the lives of our patients and their loved 

ones can be enriched. 

Since the implementation of the Mental Health Strategic Plan, VHA has dedi- cated more than $458 million to improve access and quality of care for veterans who 

present with SUD treatment needs. We have authorized the establishment of 510 

new substance use counselors and plan to continue expanding SUD services 

throughout Fiscal Year 2008 (FY 2008) and FY 2009. In FY 2008, for example, our 

mental health enhancement budget includes over $37.5 million for expanded SUD 

services. VA is developing plans to allocate medical care funds from the FY 2008 

funding to hire even more new professionals, develop new programs, expand existing 

services, and create an appropriate physical environment for care by upgrading the 

safety and physical structure of inpatient psychiatry wards, as well as domiciliary 

and residential rehabilitation programs. 

VA has increased the number of intensive outpatient SUD programs and plans 

further expansion. This reflects the continued transition from inpatient care to more 

effective intensive outpatient care for treating substance abuse problems. 

These efforts will increase access to substance abuse services throughout VA. 

Whenever a veteran is seen by a VA provider, he or she is screened for PTSD, 

military sexual trauma, depression, and problem drinking. We recognize screening 

is only valuable if we act upon positive screens and follow-up in a timely manner, 

and we are committed to doing that. 

For those needing additional services, VA’s outpatient and inpatient SUD programs are available; there are more than 220 programs in place, with more in development. Detoxification services may be offered in inpatient units such as medicine, 

psychiatry, or inpatient chemical dependency units, but the majority of patients requiring detoxification are managed on an outpatient or ambulatory basis. Following 

detoxification, substance use disorder patients are generally seen in outpatient specialty clinics. VA maintains extended care facilities, including 19 inpatient programs 

designed specifically to treat SUD patients for 14 to 28 days. Additionally, there are 

44 SUD residential rehabilitation treatment facilities, 15 SUD compensated work 

therapy programs, and 19 SUD focused domiciliaries. We also offer mental health 

intensive case management, where teams of VA health care providers visit patients 

in their own living arrangements. 

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Most SUD patients are treated once or twice a week in outpatient clinics, while 

others may require more intensive outpatient care for a minimum of four hours per 

day. Thirty-four of the intensive outpatient facilities have the capability of offering 

treatment five days a week, and telemedicine services are offered to patients living 

in remote sites. Veterans with serious mental illness in addition to SUD, are seen 

in specialized programs, such as intensive outpatient substance use disorder clinics, 

mental health intensive case management, psychosocial rehabilitation and recovery 

day programs, and work programs. 

Common elements of treatment for SUD include FDA-approved medications, employment of cognitive-behavioral therapies, incorporation of peer support groups 

(such as Alcoholics Anonymous), enlistment of the support of significant others, and 

linking the veteran to community services. 

Mental healthcare, including attention to SUD, is being integrated into primary 

care clinics, and we also are integrating mental health services into VA’s Community Based Outpatient Clinics (CBOCs), VA nursing homes, and residential care facilities. Placing mental health providers in the context of primary care for the veteran is essential; it recognizes the interrelationships of mental and physical health, 

as well as providing mental healthcare at the most convenient and desirable location for the veteran. 

VA has allocated $57.6M over the last three years to expand the capacity of our 

Domiciliary and Residential Rehabilitation Treatment (DRRT) bed programs. This 

expansion relieves pressure on acute psychiatric and SUD beds, but more importantly, these Residential Rehabilitation programs provide a therapeutic placement 

for recovering patients in a longer term rehabilitation setting. They offer intensive 

therapy experiences, well beyond what is offered in acute inpatient programs, and 

thus are a more appropriate level of care for the veteran. VA funded eleven new 

DRRT programs between FY 2005 and FY 2007, and during that same period, enhanced staffing for specialized services, like SUD treatment, in fifteen others. 

VA employs full and part time psychiatrists and full and part time psychologists 

who work in collaboration with social workers, mental health nurses, counselors, rehabilitation specialists, and other clinicians to provide a full continuum of mental 

health services for veterans. We have steadily increased the number of these mental 

health professionals over the last two and a half years. Currently, we have hired 

over 3,800 new mental health staff in that time period, for a total mental health 

staff of over 16,500. Appropriate attention to the physical and mental health needs 

of veterans will have a positive impact on their successful re-integration into civilian 

life. 

In addition to the care offered in medical facilities and CBOCs, VA’s Vet Centers 

provide outreach and readjustment counseling services to returning war veterans of 

all eras. It is well-established that rehabilitation for war-related PTSD, SUD, and 

other military-related readjustment problems, along with the treatment of the physical wounds of war, is central to VA’s continuum of healthcare programs specific to 

the needs of war veterans. The Vet Center service mission goes beyond medical care 

in providing a holistic mix of services designed to treat the veteran as a whole person in his/her community setting. Vet Centers provide an alternative to traditional 

mental healthcare that helps many combat veterans overcome the stigma and fear 

related to accessing professional assistance for military-related problems. Vet Centers are staffed by interdisciplinary teams that include psychologists, nurses and social workers, many of whom are veteran peers. 

Vet Centers provide professional readjustment counseling for war-related psychological readjustment problems, including PTSD counseling. Other readjustment 

problems may include family relationship problems, lack of adequate employment, 

lack of educational achievement, social alienation and lack of career goals, homelessness and lack of adequate resources, and other psychological problems such as depression and/or SUD. Vet Centers also provide military-related sexual trauma counseling, bereavement counseling, employment counseling and job referrals, preventive 

healthcare information, and referrals to other VA and non-VA medical and benefits 

facilities. 

VA is currently expanding the number of its Vet Centers. In February 2007, VA 

announced plans to establish 23 new Vet Centers increasing the number nationally 

from 209 to 232. This expansion began in 2007 and is planned for completion in 

2008. Fifteen of the new Vet Centers have hired staff and are fully open. Five Vet 

Centers have hired staff and are providing client services, but are operating out of 

temporary space while they finalize their lease contracts. The three remaining Vet 

Centers are actively pursuing and/or completing staff recruiting and lease contracting. They will all be open by the end of the fiscal year. 

To enhance access to care for veterans in underserved areas, some Vet Centers 

have established telehealth linkages with VA medical centers that extend VA menwwoods2 on PRODPC68 with HEARING

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tal health service delivery to remote areas to underserved veteran populations, including Native Americans on reservations at some sites. Vet Centers also offer telehealth services to expand the reach to an even broader audience. Vet Centers address veterans’ psychological and social readjustment problems in convenient, easyto-access community-based locations and generally support ongoing enhancements 

under the VA Mental Health Strategic Plan. 

Since hostilities began in Afghanistan and Iraq, the focus of the Vet Center program has been on aggressive outreach at military demobilization and at National 

Guard and Reserve sites, as well as at other community locations that feature high 

concentrations of veterans and family members. To promote early intervention, the 

Vet Center program hired 100 OEF and OIF veteran returnees to provide outreach 

services to their fellow combatants. These fellow veteran outreach specialists are effective in mitigating veterans’ fear and stigma associated with seeking professional 

counseling services. 

From early in FY 2003 through the end of FY 2007, Vet Centers have provided 

readjustment services to over 268,987 veteran returnees from OEF and OIF. Of this 

total, more than 205,481 veterans were provided outreach services, and 63,506 were 

provided substantive clinical readjustment services in Vet Centers. 

VA’s research program also demonstrates our commitment to providing the best 

care possible for veterans with substance use disorders. The VA Office of Research 

and Development (ORD) directly funds approximately 100 active research studies of 

addictive disorders, including basic biological mechanisms of dependence, abuse and 

relapse, as well as genetics of alcoholism, treatments of alcoholism, drug abuse, and 

nicotine addiction. Many of VA’s most eminent scientists, including a large cadre of 

VA Research Career scientists and our 2004 Middleton Awardee (VA’s highest honor 

for medical research), are devoting their careers to further understanding and treating substance use disorders in the veteran population. ORD is also working closely 

with the National Institutes of Health, specifically the National Institute of Mental 

Health and the National Institute of Drug Abuse, to forge research collaborations 

on substance abuse co-morbidities with mental illness, such as PTSD. 

Substance use disorder is a real problem, and its manifestation along with other 

mental health conditions can lead to physical health concerns, difficulty readjusting 

to civilian life, and a host of other problems. One of VA’s highest priorities is to reduce the impact of substance abuse and provide veterans with the care they need. 

Thank you for your time and for the opportunity to discuss this important issue 

with you. I would be happy to address any questions you may have. 

f 

Statement of Joseph L. Wilson 

Deputy Director, Veterans Affairs and Rehabilitation Commission, 

American Legion 

Mr. Chairman and Members of the Subcommittee: 

Thank you for this opportunity to present The American Legion’s views on ‘‘Substance Abuse/Co-Morbid Disorders: Comprehensive Solutions to a Complex Problem.’’ 

According to the Government Accountability Office (GAO), the Department of Veterans Affairs (VA) drastically reduced its substance-use disorder treatment and rehabilitation services between 1996 and 2006. The number of veterans receiving specialized substance abuse treatment services has since decreased by 18 percent. According to VA records, the total of mental health cases among war veterans grew 

by 58% from 63,767 on June 30, 2006, to 100,580 on June 30, 2007. These mental 

health issues include Post Traumatic Stress Disorder (PTSD), drug and alcohol dependency and depression. 

VA’s Antoinette Zeiss, Deputy Chief of Mental Health Services, acknowledged VA 

is seeing the increase (in mental health cases) and is preparing to deal with it. Mr. 

Chairman, these facts suggests a system that’s experiencing an increase, which also 

warrants the appropriate increase in staffing, funding, and clinical inpatient, outpatient and outreach programs. As for the decrease of substance abuse treatment 

services, with the influx of veterans seeking treatment, the possibility of them falling through the cracks is heightening. 

The Diagnostic Statistical Manual IV (DSM) defines substance-use disorders as 

dependence or abuse of drugs or alcohol. When discussing treatment for veterans 

within PTSD clinics, the terminology, substance abuse, is included in the definition 

of substance-use disorders. 

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Post Traumatic Stress Disorder and Substance Abuse 

In veteran and population samples, substance-use disorders co-occur with Post 

Traumatic Stress Disorder (PTSD). Symptoms of PTSD include hyper-vigilance, irritability, outbursts of anger, sleeplessness and fatigue, and can be accompanied by 

alcoholism, depression, anxiety and substance abuse. 

VA has acknowledged some veterans with PTSD treat their own symptoms with 

alcohol and wind up with diagnoses related to drug abuse. VA also acknowledges 

when veterans screen positive for symptoms of PTSD, they are interested in whether or not these also veterans have accompanied problems, such as, problem drinking 

and other problems. 

According to VA, there was a time in the past when coexisting conditions may 

have been barriers to care, when it was difficult to treat patients with PTSD and 

substance abuse due to PTSD programs requiring veterans to be sober and substance-abuse programs requiring them to be stable. VA claims this no longer occurs 

due to evidence-based strategies for beginning PTSD and substance abuse treatment 

simultaneously. One approach, the program titled, ‘‘Seeking Safety,’’ is being disseminated throughout the VA medical system. 

H.R. 4053 Mental Health Improvement Act of 2007 

Section 102 includes provision of substance-use disorder treatment services at 

each VA Medical Center (VAMC) and Community Based Outpatient Clinic (CBOC). 

These services are as follows: 

• short term motivational counseling; 

• intensive outpatient care; relapse prevention; 

• ongoing aftercare and outpatient counseling; 

• opiate substitution therapy; 

• pharmacological treatments aimed at reducing craving for drugs and alcohol; 

• detoxification and stabilization; and 

• other services as deemed appropriate. 

Section 103 recommends VA provide veterans either inpatient or outpatient care 

for a substance-use disorder and a co-morbid mental health disorder, and ensure 

that treatment for such disorders is provided concurrently by a team of clinicians 

with appropriate expertise. 

Section 104 calls for the enhancement of care and treatment for veterans with 

substance-use disorders and PTSD, which is to be carried out through a competitive 

allocation of funds to facilities of VA for the provision of care and treatment to veterans who suffer from the aforementioned. Section 104 further suggests usage of 

Peer Outreach programs to re-engage veterans of Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) who miss multiple appointments for treatment 

of PTSD or substance use disorder. 

Mr. Chairman, Congress and VA have acknowledged the appropriate treatment 

programs implemented to ensure inclusive treatment of substance abuse within the 

PTSD clinical environment. However, if studies are concluding a decline in treatment for substance abuse within the VA healthcare delivery system, this would suggest a gross lack of communication and outreach in which to ensure a high concentration of treatment, thereby maximizing the chance of the nation’s veterans of 

slipping through the cracks, as well as continued substance abuse. 

The American Legion holds the position that veterans who succumb to self-medication caused by their service-connected disability, such as PTSD, are entitled to a 

level of compensation that reflects all aspects of their disability. We also urge Congress to support the aforementioned proposals of H.R. 4053, to include assessing 

and/or auditing the implemented programs throughout the VA healthcare delivery 

system to ascertain whether or not all veterans have access or are accessing these 

programs. 

Conclusion 

As for programs and supporting regulations currently in place; the nation’s veterans continue to be deprived of treatment for substance abuse secondary to PTSD, 

which suggests an interruption and or gap in comprehensive care that ensures adequate treatment. Not meeting this mark also implies incomplete treatment which 

further invalidates the term, ‘‘full continuum of care’’ for those who served this nation with honor. 

In addition, if proposals such as H.R. 4053 are required to heighten outreach, disseminate appropriate treatment, and reassure acknowledgement of the implementation of related programs throughout the entire VA population, thereby guaranteeing 

the nation’s veterans receive specialty care within the PTSD clinical environment, 

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we encourage execution of such proposals. The American Legion supports the consistency of treatment throughout the veteran population nationwide, to include clinical programs in VAMC’s, CBOC’s, Vet Centers and related VA facilities. 

Mr. Chairman and members of the Subcommittee, The American Legion sincerely 

appreciates the opportunity to submit testimony and looks forward to working with 

you and your colleagues to resolve this critical issue. Thank you. 

f 

Statement of Hon. Jeff Miller, Ranking Republican Member, 

Subcommittee on Health, and a Representative in Congress from the State 

of Florida 

Thank you, Mr. Chairman: 

The physical and mental demands of military service including exposure to combat trauma and balancing both military and family responsibilities make those who 

bravely defend our freedoms at a higher risk for developing substance use disorders. 

I am very concerned about recent reports showing substance use disorders may 

be rising, particularly among younger veterans, and that many of these veterans 

suffering with substance use disorders also have other co-occurring mental health 

problems. 

In recent years, the VA has made progress in screening veterans and expanding 

treatment programs for substance use disorders. 

Still, the stigma associated with the substance use disorders and limited access 

to comprehensive treatment in many rural areas, keep veterans, especially those 

with co-occurring disorders, from getting the help and care they need. 

Substance use disorders can be treated and recovery is possible. That is why it 

is critically important that we understand the nature of substance use disorder 

among our veterans and effectively break the barriers that prevent them from obtaining treatment services. 

Chairman Michaud and I have joined in a bipartisan effort in introducing the Veterans Substance Use Prevention and Treatment Act of 2008. 

Our bill, H.R. 5554, would require each VA medical facility to provide ready access to comprehensive care for substance use disorders. Screening would be required 

in all settings, including primary care. Detoxification, intensive outpatient care, relapse prevention services, residential treatment, peer-to-peer counseling and marital 

and family counseling would be among the required services. 

The legislation will also direct VA to conduct a pilot program for Internet-based 

substance use disorder treatment for veterans of Operations Iraqi Freedom and Enduring Freedom (OIF/OEF). 

This new generation of veterans is comfortable with computer technology. This 

program will allow VA to utilize new and innovate ways to reach those in need and 

hopefully help overcome the stigma that can be a large barrier to care for many 

military personnel. 

Substance use disorders complicated by co-occurring mental illnesses are difficult 

to treat. Underscoring the need for VA to focus on early detection, the dissemination 

of best practices and implementing a full continuum of care throughout the VA system. 

I look forward to hearing from our witnesses today and working together to support effective treatment and empowering those veterans who develop a substance 

use disorder to overcome their condition and lead productive lives. 

I want to thank everyone that is here today for taking the time to be a part of 

this important hearing and yield back the balance of my time. 

Æ 

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