II 116th CONGRESS 1st Session S. 2991 IN THE SENATE OF THE UNITED STATES December 5, 2019 Mr. Sullivan (for himself and Ms. Baldwin ) introduced the following bill; which was read twice and referred to the Committee on Veterans' Affairs A BILL To direct the Secretary of Veterans Affairs to conduct an independent review of the deaths of certain veterans by suicide, and for other purposes.

1. Short title This Act may be cited as the Veteran Overmedication and Suicide Prevention Act of 2019 . 2. Department of Veterans Affairs independent review of certain deaths of veterans by suicide (a) Review required (1) In general Not later than 90 days after the date of the enactment of this Act, the Secretary of Veterans Affairs shall seek to enter into an agreement with the National Academies of Sciences, Engineering, and Medicine under which the National Academies shall conduct a review of the deaths of all covered veterans who died by suicide during the five-year period ending on the date of the enactment of this Act, regardless of whether information relating to such deaths has been reported by the Centers for Disease Control and Prevention. (2) Elements The review required by paragraph (1) shall include the following: (A) The total number of covered veterans who died by suicide during the five-year period ending on the date of the enactment of this Act. (B) The total number of covered veterans who died by a violent death during such five-year period. (C) The total number of covered veterans who died by an accidental death during such five-year period. (D) A description of each covered veteran described in subparagraphs (A) through (C), including age, gender, race, and ethnicity. (E) A comprehensive list of prescribed medications and legal or illegal substances as annotated on toxicology reports of covered veterans described in subparagraphs (A) through (C), specifically listing any medications that carried a black box warning, were prescribed for off-label use, were psychotropic, or carried warnings that included suicidal ideation. (F) A summary of medical diagnoses by physicians of the Department of Veterans Affairs or physicians providing services to covered veterans through programs of the Department that led to the prescribing of medications referred to in subparagraph (E) in cases of post-traumatic stress disorder, traumatic brain injury, military sexual trauma, and other anxiety and depressive disorders. (G) The number of instances in which a covered veteran described in subparagraph (A), (B), or (C) was concurrently on multiple medications prescribed by physicians of the Department or physicians providing services to veterans through programs of the Department to treat post-traumatic stress disorder, traumatic brain injury, military sexual trauma, other anxiety and depressive disorders, or instances of comorbidity. (H) The number of covered veterans described in subparagraphs (A) through (C) who were not taking any medication prescribed by a physician of the Department or a physician providing services to veterans through a program of the Department. (I) With respect to the treatment of post-traumatic stress disorder, traumatic brain injury, military sexual trauma, or other anxiety and depressive disorders, the percentage of covered veterans described in subparagraphs (A) through (C) who received a non-medication first-line treatment compared to the percentage of such veterans who received medication only. (J) With respect to the treatment of covered veterans described in subparagraphs (A) through (C) for post-traumatic stress disorder, traumatic brain injury, military sexual trauma, or other anxiety and depressive disorders, the number of instances in which a non-medication first-line treatment (such as cognitive behavioral therapy) was attempted and determined to be ineffective for such a veteran, which subsequently led to the prescribing of a medication referred to in subparagraph (E). (K) A description and example of how the Department determines and continually updates the clinical practice guidelines governing the prescribing of medications. (L) An analysis of the use by the Department, including protocols or practices at medical facilities of the Department, of systematically measuring pain scores during clinical encounters under the Pain as the 5th Vital Sign Toolkit of the Department and an evaluation of the relationship between the use of such measurements and the number of veterans concurrently on multiple medications prescribed by physicians of the Department. (M) A description of the efforts of the Department to maintain appropriate staffing levels for mental health professionals, such as mental health counselors, marriage and family therapists, and other appropriate counselors, including— (i) a description of any impediments to carry out the education, training, and hiring of mental health counselors and marriage and family therapists under section 7302(a) of title 38, United States Code, and strategies for addressing those impediments; (ii) a description of the objectives, goals, and timing of the Department with respect to increasing the representation of such counselors and therapists in the behavioral health workforce of the Department, including— (I) a review of eligibility criteria for such counselors and therapists and a comparison of such criteria to that of other behavioral health professions in the Department; and (II) an assessment of the participation of such counselors and therapists in the mental health professionals trainee program of the Department and any impediments to such participation; (iii) an assessment of the development by the Department of hiring guidelines for mental health counselors, marriage and family therapists, and other appropriate counselors; (iv) a description of how the Department— (I) identifies gaps in the supply of mental health professionals; and (II) determines successful staffing ratios for mental health professionals of the Department; (v) a description of actions taken by the Secretary, in consultation with the Director of the Office of Personnel Management, to create an occupational series for mental health counselors and marriage and family therapists of the Department and a timeline for the creation of such an occupational series; and (vi) a description of actions taken by the Secretary to ensure that the national, regional, and local professional standards boards for mental health counselors and marriage and family therapists are comprised of only mental health counselors and marriage and family therapists and that the liaison from the Department to such boards is a mental health counselor or marriage and family therapist. (N) The percentage of covered veterans described in subparagraphs (A) through (C) with combat experience or trauma related to combat experience (including military sexual trauma, traumatic brain injury, and post-traumatic stress). (O) An identification of the medical facilities of the Department with markedly high prescription rates and suicide rates for veterans receiving treatment at those facilities. (P) An analysis, by State, of programs of the Department that collaborate with State Medicaid agencies and the Centers for Medicare and Medicaid Services, including the following: (i) An analysis of the sharing of prescription and behavioral health data for veterans. (ii) An analysis of whether Department staff check with State prescription drug monitoring programs before prescribing medications to veterans. (iii) A description of the procedures of the Department for coordinating with prescribers outside of the Department to ensure that veterans are not overprescribed. (iv) A description of actions that the Department takes when a veteran is determined to be overprescribed. (Q) An analysis of the collaboration of medical centers of the Department with medical examiners’ offices or local jurisdictions to determine veteran mortality and cause of death. (R) An identification and determination of a best practice model to collect and share veteran death certificate data between the Department of Veterans Affairs, the Department of Defense, States, and tribal entities. (S) A description of how data relating to death certificates of veterans is collected, determined, and reported by the Department of Veterans Affairs. (T) An assessment of any patterns apparent to the National Academies of Sciences, Engineering, and Medicine based on the review conducted under paragraph (1). (U) Such recommendations for further action that would improve the safety and well-being of veterans as the National Academies of Sciences, Engineering, and Medicine determine appropriate. (3) Compilation of data (A) Form of compilation The Secretary of Veterans Affairs shall ensure that data compiled under paragraph (2) is compiled in a manner that allows it to be analyzed across all data fields for purposes of informing and updating clinical practice guidelines of the Department of Veterans Affairs. (B) Compilation of data regarding covered veterans In compiling data under paragraph (2) regarding covered veterans described in subparagraphs (A) through (C) of such paragraph, data regarding veterans described in each such subparagraph shall be compiled separately and disaggregated by year. (4) Completion of review and report The agreement entered into under paragraph (1) shall require that the National Academies of Sciences, Engineering, and Medicine complete the review under such paragraph and submit to the Secretary of Veterans Affairs a report containing the results of the review not later than 180 days after entering into the agreement. (b) Report Not later than 30 days after the completion by the National Academies of Sciences, Engineering, and Medicine of the review required under subsection (a), the Secretary of Veterans Affairs shall— (1) submit to the Committee on Veterans’ Affairs of the Senate and the Committee on Veterans’ Affairs of the House of Representatives a report on the results of the review; and (2) make such report publicly available. (c) Definitions In this section: (1) The term black box warning means a warning displayed on the label of a prescription drug that is designed to call attention to the serious or life-threatening risk of the prescription drug. (2) The term covered veteran means a veteran who received hospital care or medical services furnished by the Department of Veterans Affairs during the five-year period preceding the death of the veteran. (3) The term first-line treatment means a potential intervention that has been evaluated and assigned a high score within clinical practice guidelines. (4) The term State means each of the States, territories, and possessions of the United States, the District of Columbia, and the Commonwealth of Puerto Rico.