In fiscal year 2018, VHA data show that 518,570 veterans received any treatment (specialty or non-specialty services) from VHA’s health care systems for a diagnosed SUD, a 9.5 percent increase from fiscal year 2016 (see figure 1). Because these data include non-specialty services, the data do not indicate the extent to which the veteran received SUD services. For example, a provider briefly discussing the SUD of a veteran in long-term recovery during a primary care visit would be included in SUD treatment data. VHA data show that the majority of veterans who received any treatment from VHA’s health care systems for a diagnosed SUD had an alcohol use disorder. Veterans received any treatment from VHA for a diagnosed SUD at a higher rate than the general population. Data from the 2017 National Survey on Drug Use and Health indicate that 1.5 percent of individuals aged 18 or older nationwide received any SUD treatment in the past year. In comparison, 8 percent of veterans getting health care provided or purchased by VHA received any treatment for a diagnosed SUD in fiscal year 2017, including individuals who received specialty SUD services as well as individuals who received non-specialty services in, for example, primary care or general mental health clinics. VHA’s health care systems provide specialty SUD services in three settings increasing in intensity (see figure 2): Outpatient services. Individual and group therapy, either in person or via telehealth, among other services. VHA also offers intensive outpatient programs, which provide services for 3 or more hours per day, 3 days a week at a minimum. Residential rehabilitation treatment programs. Medically monitored, high-intensity care in a 24-hour supervised environment specifically dedicated to treating SUDs. These programs may also provide social services for community reintegration and treatment for other medical conditions during a veteran’s stay. Inpatient services. Acute in-hospital care, which may include detoxification services. For veterans with opioid use disorder—a subset of SUDs—VHA’s health care systems provide medication-assisted treatment. Medication- assisted treatment combines behavioral therapy and the use of certain medications, including methadone and buprenorphine. Medication- assisted treatment has proven to be clinically effective in reducing the need for inpatient detoxification services for individuals with opioid use disorder, according to SAMHSA. Methadone. This medication suppresses withdrawal symptoms during detoxification. It also controls the craving for opioids in maintenance therapy, which is ongoing therapy meant to prevent relapse and increase treatment retention. Methadone is a controlled substance and, when used to treat opioid use disorder, may generally be administered or dispensed only within a certified opioid treatment program to help prevent diversion. Buprenorphine. This medication eliminates opioid withdrawal symptoms, including drug cravings, and it may do so without producing the euphoria or dangerous side effects of other opioids. It can be used for detoxification and maintenance therapy. Buprenorphine is also a controlled substance, and when used to treat opioid use disorder, may be administered or dispensed within an opioid treatment program, or prescribed or dispensed by a qualifying provider who has received a waiver to do so. Providers who receive this waiver are limited in the number of patients they may treat for opioid use disorder. In addition to medication-assisted treatment, VHA has initiatives aimed at preventing opioid-related overdose deaths. For example, VHA’s Opioid Overdose Education and Naloxone Distribution program includes education and training regarding opioid overdose prevention as well as naloxone distribution. Naloxone is a medication that can reverse opioid overdoses. Veterans may receive services from community providers via local contracts or community care. For local contracts, individual VA medical centers establish contracts with local community providers. For example, a VA medical center may develop a contract with a community residential rehabilitation treatment program provider to set aside a number of beds specifically for veterans. For community care, veterans may be eligible if, for example, VHA does not offer the care or service the veteran requires or VHA cannot provide the care or services consistent with its access standards. In general, community care services must be authorized in advance of when veterans access the care. Prior to June 6, 2019, eligible veterans could receive community care via one of multiple VHA community care programs. In 2018, the VA MISSION Act required VA to implement a permanent community care program that consolidated several community care programs. On June 6, 2019, the consolidated community care program, the Veterans Community Care Program, went into effect. Among the 518,570 veterans who received SUD services in fiscal year 2018, VHA provided specialty SUD services to 152,482 veterans in fiscal year 2018. This number has increased slightly but remained relatively unchanged since fiscal year 2014, as shown in table 1 below. These veterans received care in VHA’s health care systems—that is, in VA medical centers or in one of the medical centers’ affiliated outpatient clinics and other medical facilities. During the same time period, VHA expenditures for these specialty SUD services increased from $552 million in fiscal year 2014 to $601 million in fiscal year 2018. Total specialty SUD expenditures per capita increased from $3,691 to $3,941 from fiscal years 2014 through 2018. Adjusted for inflation, however, per capita expenditures remained relatively unchanged between fiscal years 2014 and 2018. Our analysis of VHA data shows that veterans received specialty SUD services from VHA’s health care systems in multiple settings from fiscal years 2014 through 2018, with most veterans receiving these services in outpatient settings. Veterans may receive specialty SUD services across multiple settings within a year. Below, we provide information on utilization and expenditures for specialty SUD services in outpatient and residential treatment programs and for medication-assisted treatment for veterans with opioid use disorder. In fiscal year 2018, nearly all veterans who received specialty SUD services from VHA’s health care systems received this care in outpatient settings at some point during the year. Of those veterans who received outpatient specialty SUD services, 17 percent received intensive outpatient specialty SUD services, with little change from previous years. Expenditures for outpatient specialty SUD services increased from fiscal years 2014 through 2018, as shown in table 2 below. During this time period, outpatient specialty SUD expenditures per capita increased from $2,176 to $2,348. Adjusted for inflation, per capita expenditures grew 1.5 percent between fiscal years 2014 and 2018. In addition, we found little change in the number of full-time employee equivalents that actively provided outpatient specialty SUD services from fiscal years 2015 through 2018. VHA did not provide specialty outpatient wait-time data because, according to VHA officials, the data do not reliably capture veterans’ wait times to receive SUD services in outpatient settings. VHA officials explained that veterans may receive non-specialty SUD services in various outpatient settings, including primary care and general mental health clinics. Therefore, developing a wait-time measure for specialty SUD services would not accurately capture whether veterans are waiting for SUD services not previously provided or services that would continue ongoing treatment begun in a primary care or general mental health clinic. As a result, we did not analyze outpatient wait-time data. In prior work, we have made recommendations to VHA on ways it can improve its outpatient wait-time data (see sidebar). As of fiscal year 2018, VHA had residential rehabilitation treatment programs available for veterans with complex and long-term mental health needs at 113 facilities, and 67 of these programs were dedicated to SUD treatment. The number of residential rehabilitation treatment programs dedicated to SUD treatment increased from fiscal years 2014 through 2018, as did the number of beds available. Figure 3 shows the location of all 67 residential rehabilitation treatment programs specifically dedicated to SUDs with the corresponding number of beds in fiscal year 2018. See appendix III for more information on residential rehabilitation treatment programs dedicated to SUD treatment. The number of veterans participating in VHA’s specialty SUD residential rehabilitation treatment programs (that is, those dedicated to SUD treatment) remained relatively stable from fiscal years 2014 through 2018, as shown in table 3. Of the veterans who received specialty SUD services in fiscal year 2018, approximately 10 percent participated in one of VHA’s 67 residential rehabilitation treatment programs dedicated to SUD treatment, similar to previous years. Meanwhile, expenditures for VHA’s residential rehabilitation treatment programs dedicated to SUD decreased from fiscal years 2014 through 2016, but increased in fiscal years 2017 and 2018. Similarly, specialty SUD residential expenditures per capita decreased from $15,386 in fiscal year 2014 to $12,526 in fiscal year 2016 and increased again to $16,031 in fiscal year 2018. After adjusting for inflation, specialty SUD residential expenditures per capita in 2018 were about 2 percent less than what they were in 2014. From fiscal years 2014 to 2018, veterans’ average length of stay for VHA’s specialty residential rehabilitation treatment programs specifically dedicated to SUD generally decreased, while wait times varied across programs. Across VHA’s residential rehabilitation treatment programs dedicated to SUD treatment, veterans’ average length of stay generally decreased from fiscal years 2014 to 2018, from nearly 40 days to nearly 36 days. VHA officials said that average length of stay may have decreased as a result of multiple factors, such as programs with longer lengths of stay adjusting their treatment approaches. The median wait times to enter residential rehabilitation treatment programs dedicated to SUD treatment varied considerably, ranging from 0 days to 56 days across the programs in fiscal year 2018, although not all residential rehabilitation treatment programs had sufficient—and therefore reliable— data on wait times. Specifically, out of the 67 residential rehabilitation treatment programs dedicated to SUD, VHA officials identified 12 that did not have sufficient wait-time data, which we excluded from our analysis. VHA officials noted that some specialty residential rehabilitation treatment programs do not have sufficient wait-time data because the facilities do not consistently code whether a patient’s visit included a screening for admission to the program. As such, VHA cannot tell when patients were initially screened for admission. In fiscal year 2019, officials implemented changes to address the lack of reliable data from some facilities. However, it is too early to tell if the new changes will address the data reliability issues in wait-time data for residential rehabilitation treatment programs. VHA health care systems offer veterans medication-assisted treatment for opioid use disorder in a variety of settings, including outpatient specialty SUD settings and residential rehabilitation treatment programs dedicated to SUD treatment, as well as in non-specialty settings, such as primary care and general mental health clinics. Our analysis of VHA data shows the number and proportion of veterans with an opioid use disorder who received medication-assisted treatment from VHA’s health care systems has risen in recent years, as shown in table 4. In fiscal year 2018, 23,798 veterans received medication-assisted treatment, which was 33.6 percent of veterans diagnosed with an opioid use disorder. Veterans with an opioid use disorder may receive medication-assisted treatment through VHA at a lower rate than individuals who received care through private insurance. According to a study by the Department of Health and Human Services, 50.6 percent of individuals diagnosed with an opioid use disorder and enrolled in private insurance received medication-assisted treatment in 2014 to 2015. Some veterans may also have private insurance and may have received their medication-assisted treatment through that private insurance. In fiscal year 2018, 9,132 (38 percent) of the veterans who received medication-assisted treatment received their care at one of VHA’s 33 opioid treatment programs, which is the only setting where methadone can be administered to treat opioid use disorder. Expenditures for these opioid treatment programs increased from $35.9 million in fiscal year 2014 to $39.1 million in fiscal year 2018. In fiscal year 2018, VHA had 2,036 providers with a waiver to prescribe buprenorphine, a 17.6 percent increase from fiscal year 2017. According to VHA officials, VHA has encouraged its providers—including those who are not specialists in treating SUDs, such as primary care providers—to obtain the waiver required to prescribe buprenorphine to treat opioid use disorder. In fiscal year 2018, there were about 29 VHA providers with a waiver to prescribe buprenorphine for every 1,000 veterans with opioid use disorder, a 14 percent increase from fiscal year 2017. VHA’s naloxone kit distribution increased exponentially from 646 in fiscal year 2014 to 97,531 kits in fiscal year 2018. A total of 204,557 naloxone kits have been distributed through fiscal year 2018. VHA health care systems distributed naloxone kits to VA staff, including VA first responders and VA police officers, and veterans with opioid use disorder. Factors contributing to the increase may include: In 2014, VHA implemented the Opioid Overdose Education and Naloxone Distribution initiative to decrease opioid-related overdose deaths among veterans, with one of its key components focused on encouraging naloxone kit distribution. Since the program’s implementation, all VHA health care systems dispense naloxone kits. The Comprehensive Addiction and Recovery Act of 2016 directed VHA to maximize the availability of naloxone to veterans and to ensure that veterans who are considered at risk for opioid overdose have access to naloxone and training on its proper administration. Veterans Health Administration (VHA) Community Care Wait Times GAO has a body of work highlighting challenges VHA has with the reliability of its wait-time data. See below for recent reports about this issue. We have highlighted the importance of reliable community care wait-time data in a testimony regarding VHA’s efforts to address our previous recommendations on these issues. See GAO, Veterans Health Care: Opportunities Remain to Improve Appointment Scheduling within VA and through Community Care, GAO-19-687T (Washington, D.C.: July 24, 2019). We have designated our past recommendations related to community care wait-time data as priorities for the agency. See GAO, Priority Open Recommendations: Department of Veterans Affairs, GAO-19- 358SP (Washington, D.C.: Mar. 28, 2019). We have previously made recommendations to VHA to capture the necessary information and improve the reliability of wait-time data for community care. These recommendations remain outstanding as of October 2019. See GAO, Veterans Choice Program: Improvements Needed to Address Access- Related Challenges as VA Plans Consolidation of its Community Care Programs, GAO-18-281 (Washington, D.C.: June 4, 2018). Through its community care programs, VHA purchased SUD services (specialty and non-specialty) for 20,873 veterans in fiscal year 2018, a significant increase since fiscal year 2014 (see table 5). VHA officials noted that veterans can receive community care in addition to, or instead of, care at a VHA facility; therefore, the number of veterans served through community care cannot be combined with the number who received services within VHA to provide an overall number of veterans receiving care. Expenditures for these SUD services purchased by VHA also increased over time, from nearly $6 million in fiscal year 2014 to over $80 million in fiscal year 2018. Between fiscal years 2014 and 2018, on a per capita basis, SUD services purchased by VHA increased from $3,021 to $3,852. Per capita expenditures adjusted for inflation also increased during this time period. These increases coincided with the establishment of the Veterans Choice Program in early fiscal year 2015, which expanded eligibility for community care. Wait-time data for SUD services purchased through community care were not available because of data reliability issues, VHA officials told us. See sidebar for more information on our previous recommendations to VHA regarding community care wait-time data. While VHA is able to report on the overall number of veterans receiving SUD services through community care, data limitations prevent VHA officials from reliably determining whether veterans received this care in residential or outpatient settings. These issues are as follows: Residential rehabilitation treatment programs. VHA uses billing codes on paid claims to track the settings in which veterans receive community care; however, according to agency officials, there is no specific billing code for a residential setting. VHA officials told us that community residential rehabilitation treatment programs may record treatment provided using inpatient or outpatient billing codes—or a combination of the two—in submitting claims to VHA. As a result, VHA is unable to use claims data to reliably identify veterans who received residential rehabilitation treatment through community care. Outpatient settings. Because some residential care data are coded using outpatient billing codes, outpatient data may contain residential services counted as outpatient services. As a result, VHA is unable to reliably identify veterans who received SUD services in community care outpatient settings. Currently, VHA is taking steps to address these coding issues. VHA officials told us they are developing a payment code that will bundle together common residential program services, which will allow VHA to identify veterans receiving residential rehabilitation treatment for SUDs through community care. Officials explained that using this code for residential SUD services will allow VHA to better distinguish between residential and outpatient community care because residential care will no longer need to be identified using outpatient codes. In contrast to its community care programs, VHA does not centrally track SUD services provided via local contracts. Rather, the individual medical centers that established the contracts with local community providers are responsible for tracking and documenting SUD services provided to veterans. In fiscal year 2019, VHA began conducting market assessments, a broader agency initiative to better understand the supply and demand of all services at all VA medical centers, including both what is available within VHA as well as what is available in the local communities. We reviewed one of the data collection instruments the agency is using as a part of this work and found that it should allow VHA to identify, among other things, the number of community residential rehabilitation treatment beds contracted by individual medical centers to serve veterans with SUDs, as well as the number of veterans who received SUD services through local contracts or community care for SUDs. Agency officials said that they expect the market assessments to be completed in 2020. Although overall use of SUD services was similar among veterans in rural and urban areas, VHA data show the utilization rates of some specialty SUD services differed. The literature and agency documents we reviewed and VHA officials consistently cited several issues, such as recruiting SUD providers and accessing necessary prescriptions for SUDs, which affect the use of services by veterans with SUDs in rural areas. According to agency documents and officials, VHA is taking steps to address these issues. Overall, veterans’ use of SUD services was similar in rural areas compared to urban areas, but use of some specialty services differed. Our analysis of VHA data shows that across VHA’s 140 health care systems, there was relatively little difference in the overall utilization of SUD services (specialty and non-specialty) in rural and urban areas from fiscal years 2016 through 2018. In fiscal year 2018, for example, 7.5 percent of veterans in rural areas received any SUD services compared with 8.8 percent of veterans in urban areas. However, VHA data also show there were some types of specialty services, such as intensive outpatient specialty services, residential rehabilitation treatment programs, and medication-assisted treatment for opioid use disorder, that rural veterans with SUDs tended to use more or less of than their urban counterparts. Among veterans receiving specialty SUD services across all 140 VHA health care systems, those veterans in rural locations used intensive outpatient specialty SUD services at a slightly higher rate (19 percent) than veterans in urban locations (17 percent) in fiscal year 2018. While veterans’ utilization of these specialty SUD services has decreased in both rural and urban locations in recent years, the decreases have been larger in rural areas. In rural locations, the percentage of veterans using intensive outpatient specialty SUD services decreased from 25 percent in fiscal year 2015 to 19 percent in fiscal year 2018. In comparison, in urban areas, the percentage of veterans using these services decreased from 18 percent to 17 percent during this same time period. Officials from VHA health care systems in three urban locations and two rural locations we spoke with indicated that they offered intensive outpatient specialty SUD services in conjunction with either residential or outpatient services. According to officials from the rural VHA health care system that did not offer this service, the location did not have sufficient staff to provide the additional hours of intensive outpatient specialty SUD treatment each week. Veterans in rural locations using specialty SUD services participated in residential rehabilitation treatment programs dedicated to SUD treatment at a higher rate (17 percent) than veterans using these services in urban locations (10 percent) across all 140 VHA health care systems in fiscal year 2018. From fiscal years 2014 through 2018, there was a slight increase in the percentage of rural veterans using specialty SUD services who participated in residential rehabilitation treatment programs dedicated to SUD treatment, from 13 percent to 17 percent. VHA officials told us rural communities often face difficulties with transportation that may make residential programs more feasible than accessing intensive outpatient specialty SUD services, which are at least 3 days per week, at VHA health care systems. All six of the VHA health care systems we interviewed offered residential rehabilitation treatment programs. VHA reported the agency is currently conducting market assessments that may help determine gaps in services for veterans with SUDs, including residential rehabilitation treatment, once the assessments are complete. Across all 140 VHA health care systems, veterans with an opioid use disorder received medication-assisted treatment (in specialty and non- specialty settings) at a higher rate in urban locations (34 percent) than in rural locations (27 percent) in fiscal year 2018. We also found differences in the availability of medication-assisted treatment services between rural and urban areas: Methadone. The only setting in which methadone may be used to treat an opioid use disorder is an opioid treatment program. All of VHA’s opioid treatment programs are located in urban areas. Only one of the six selected VHA health care systems in our review had an opioid treatment program. Officials from the other five VHA health care systems we spoke with told us they typically referred out to community providers if a veteran needed methadone. Regional VHA officials indicated that some locations, especially rural ones, may not have the number of veterans with opioid use disorder needed to justify the resources required to run an opioid treatment program. Buprenorphine. The number of waivered providers per 1,000 veterans with opioid use disorder was slightly higher in rural areas (29.9 providers) than in urban areas (28.7 providers) in fiscal year 2018. Non-specialist rural providers, such as primary care providers, may feel a greater responsibility to obtain a waiver because there are fewer specialists for them to refer their patients to, according to VHA health care system officials. Despite the similar rates of waivered providers in rural and urban areas, as previously mentioned, rural veterans with opioid use disorder use medication-assisted treatment at a lower rate. VHA requires that all rural and urban health care systems offer the same range of SUD services (specialty or non-specialty). However, rural areas have historically faced difficulties delivering all types of health care, including SUD services, according to literature, agency documents, and VHA health care system officials we spoke with. VHA is taking steps to address several issues that affect the delivery of health care services generally, and SUD services in particular, in rural areas. Officials from three of the six VHA health care systems we interviewed noted a shortage of SUD specialists in their area, including addiction therapists and providers with a waiver to prescribe buprenorphine. According to one study and agency documents we reviewed, veterans may reside in mental health professional shortage areas at a higher rate than the general population, therefore they may have less access to providers qualified to offer medication-assisted treatment or other mental health treatment. One study found that efforts to improve access for veterans in rural areas by purchasing care from community providers may have limited effect, because these areas are relatively underserved generally. Officials from two of the three VHA health care systems in rural areas we selected expressed difficulty hiring and retaining providers to provide SUD services. Because of the shortages, recruiting and retaining providers to deliver care to rural veterans is critical. Based on the literature reviewed and half of VHA health care system officials interviewed, rural communities struggle with recruiting and retaining providers, including SUD providers. Some rural areas report provider shortages with ongoing, long-term vacancies. To respond to these provider shortages and hiring and retaining challenges, VHA has implemented new initiatives and practices to increase the supply of rural health professionals. A VHA official noted that these efforts include rural health training and education initiatives to provide rural health experience to health professions trainees, including those who provide SUD services. The agency also plans to use expanded recruitment tools, like greater access to an education debt reduction program, improved flexibility for bonuses for recruitment, relocation, and retention, as well as piloting a scholarship program authorized under the VA MISSION Act of 2018 to hire mental health professionals. However, recruiting health professionals in rural areas, including mental health providers and social workers, remains an issue for VHA and the community at large, and VHA officials noted that data are not yet available to understand the long-term effect of the newly trained providers on the availability of SUD services. Officials from two VHA health care systems we interviewed noted that providing services, such as medication-assisted treatment, through telehealth technology is difficult, especially when the SUD service requires monitoring for medication compliance. However, a VHA official told us the use of telehealth services overall has grown exponentially at VHA’s health care systems and goes beyond traditional video conference capabilities to include advanced technology that can be attached to computers or videoconference equipment like an exam camera to allow for an interactive examination. The official added that the provision of SUD services using telehealth can be supported by medical personnel located at the closest VA facility to complete necessary tests, such as urine screening, when the service is provided at a VHA location. VHA officials from one health care system we spoke with and literature noted that providing medication-assisted treatment via telehealth technologies requires a cultural change within the profession. Officials from one VHA health care system we spoke with told us that delivering medication-assisted treatment using technology is risky. For example, buprenorphine is a controlled substance with a risk of misuse. This official added that many providers may not be open to the idea of delivering this level of treatment using telehealth. One study we reviewed confirmed that acceptance within the profession appears to be the main barrier to the successful implementation of telehealth services. However, VHA’s budget and strategic plan show continued support for the use of telehealth for SUD treatment. Studies have shown that telephone services, a type of telehealth service, potentially have the same outcomes as in-person services. Officials from all six VHA health care systems we selected mentioned they had mental health telehealth services available to facilitate the delivery of care to veterans in both urban and rural areas for SUD services. To ensure adequate access to care, VHA has multiple telehealth initiatives underway. For example, between fiscal years 2017 and 2019, VHA allocated $28.5 million for mental health telehealth hubs at 11 sites. In another instance, VHA allocated more than $750,000 for rural facilities in fiscal years 2018 and 2019 toward a nationwide initiative to improve participation in a program that establishes video connections in the homes of rural veterans to receive mental health treatment, including for SUDs, with psychotherapy and psychopharmacology. While VHA has initiatives underway, the success of these efforts is contingent on rural areas having broadband and internet connectivity, which remains a challenge, according to agency documents and officials. VHA’s Clinical Practice Guidelines for SUDs recommends methadone and buprenorphine, among others drugs, to treat opioid use disorder. However, accessing these drugs in rural areas can be challenging, according to literature we reviewed and VHA officials we spoke with. For example, one national study found that opioid treatment programs providing methadone are generally absent from the treatment options in rural areas. Within VHA, all of the opioid treatment programs are in urban areas. In addition, in rural areas generally, a small percentage of providers nationwide have received waivers to prescribe buprenorphine. VHA officials told us they are steadily expanding the availability of medication-assisted treatment for veterans with opioid use disorder. VHA had an interdisciplinary team of VA staff from a single facility within each region receive training on implementing medication-assisted treatment for opioid use disorder. These teams were responsible for spreading information to other facilities. Thus far, VHA reported it has trained over 300 providers using this model. In a separate initiative, a VHA official reported that its Office of Rural Health provided over $300,000 in fiscal year 2019 for a pilot program that trains primary care and mental health providers in the Iowa City VHA health care system on how to provide medication-assisted treatment for opioid use disorder. The availability of transportation is vital for veterans receiving medication- assisted treatment due to the necessity for frequent travel to the VHA health care systems for treatment. When using methadone for opioid use disorder treatment, the medication generally needs to be administered through an opioid treatment program at a specific location on a daily basis. In addition, during the initial stages of buprenorphine treatment, patients must also come into a facility frequently. Veterans living in rural areas who need this level of care may have to travel long distances every day to receive this medication. Distance and lack of transportation impede access to care, including SUD services, for rural veterans. Specifically, the literature we reviewed noted distance, time, and access to transportation as barriers to care. Veterans may lack access to transportation or are no longer able to drive because of age, health status, or driving restrictions. Some rely on family, friends or vans available through community service organizations; however, they may have other difficulties like reaching pick-up locations or the organization not having vans that are wheelchair-equipped. Officials from all six VHA health care systems we selected noted the lack of transportation as a barrier to accessing SUD services. Officials from two rural locations of the six selected VHA health care systems mentioned that volunteers, including a local veteran service organization, assist with getting veterans from their homes to their appointments; however, they added that these services operate on an abbreviated schedule and veterans are sometimes subjected to riding in the vehicle for long periods of time (2 hours each way). Over the last 10 years, a VHA official told us that the agency has allocated between $10 and $12.9 million for its Veterans Transportation Service for new vehicles, drivers, and mobility managers to assist with rural transportation needs. The VA MISSION Act of 2018 includes provisions that specifically address the need to improve veterans’ access to health care in areas with shortages of health care providers, including those providing SUD and mental health services. Based on this legislation, in June 2019, VHA published a plan organized in three areas: increasing personnel, using technology to connect veterans to care through public and private partnerships, and expanding VHA’s infrastructure through the building or acquiring of space to address the problem of underserved facilities. For example, VHA has a pilot program with 11 Walmart sites and 15-20 additional sites planned with Philips Healthcare, the Veterans of Foreign Wars, and the American Legion to enable veterans who lack the necessary technology in their home and live far from a VHA facility to receive remote health care at a convenient location. VHA’s plan indicates that while all VHA health care systems can use any of the strategies covered under this legislation, they will provide specific additional technical assistance for underserved facilities, monitor the effectiveness of these strategies, and share the findings of this work throughout the broader VHA system. We provided a draft of this report to VA for review and comment. VA provided written comments, which are reprinted in appendix IV, and technical comments, which we incorporated as appropriate. VA’s comments note that the agency generally reports obligations and that the agency is unable to confirm some of our financial data. However, the data provided by VA during the course of this engagement were regarding expenditures, and thus we report them as such. VA’s comments also provide information on additional efforts to expand mental health telehealth and ways the agency recruits providers in rural areas. We are sending copies of this report to the appropriate congressional committees, the Secretary of Veterans Affairs, and other interested parties. In addition, the report is available at no charge on the GAO website at http://www.gao.gov. If you or your staff have any questions about this report, please contact me at (202) 512-7114 or at deniganmacauleym@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. GAO staff who made key contributions to this report are listed in appendix V. Figure 4, an interactive graphic, shows the location and rurality of the Veterans Health Administration’s health care systems, as well as information on veterans treated by these health care systems. For an accessible version of the data used in this map, see https://www.gao.gov/products/GAO-20-35. To describe any differences between veterans’ use of substance use disorder (SUD) services in rural and urban areas and the issues affecting access to those services in rural areas, we selected six Veterans Health Administration (VHA) health care systems and interviewed officials regarding their SUD services and issues serving veterans with SUDs. Because opioid use disorders may pose a greater risk to veterans than the general population, we selected the six VHA health care systems from among those with the highest percentages of veterans with an opioid use disorder diagnosis in fiscal year 2018. We also selected these six health care systems to achieve variation in representation among VHA’s five geographic regions and to include both urban and rural locations. See table 6. The Veterans Health Administration had 67 residential rehabilitation treatment programs dedicated to substance use disorder treatment in fiscal year 2018. See table 7. Mary Denigan-Macauley, (202) 512-7114 or deniganmacauleym@gao.gov. In addition to the contact named above, Lori Achman, Assistant Director; Hannah Marston Minter and Carolina Morgan, Analysts-in-Charge; Sam Amrhein; Amy Andresen; Shaunessye D. Curry; and John Tamariz made key contributions to this report. Also contributing were Giselle Hicks, Diona Martyn, Ethiene Salgado-Rodriguez, and Emily Wilson Schwark. Veterans Health Care: Opportunities Remain to Improve Appointment Scheduling within VA and through Community Care, GAO-19-687T. Washington, D.C.: July 24, 2019. VA Health Care: Estimating Resources Needed to Provide Community Care, GAO-19-478. Washington, D.C.: June 12, 2019. Drug Policy: Assessing Treatment Expansion Efforts and Drug Control Strategies and Programs, GAO-19-535T. Washington, D.C.: May 9, 2019. Priority Open Recommendations: Department of Veterans Affairs, GAO-19-358SP. Washington, D.C.: March 28, 2019. Behavioral Health: Research on Health Care Costs of Untreated Conditions is Limited, GAO-19-274. Washington, D.C.: Feb. 28, 2019. Veterans Choice Program: Improvements Needed to Address Access- Related Challenges as VA Plans Consolidation of its Community Care Programs, GAO-18-281. Washington, D.C.: June 4, 2018. VA Health Care: Progress Made Towards Improving Opioid Safety, but Further Efforts to Assess Progress and Reduce Risk Are Needed, GAO-18-380. Washington, D.C.: May 29, 2018. Opioid Use Disorders: HHS Needs Measures to Assess the Effectiveness of Efforts to Expand Access to Medication-Assisted Treatment, GAO-18-44. Washington, D.C.: October 31, 2017. Opioid Addiction: Laws, Regulations, and Other Factors Can Affect Medication-Assisted Treatment Access, GAO-16-833. Washington, D.C.: September 27, 2016. VA Health Care: Reliability of Reported Outpatient Medical Appointment Wait Times and Scheduling Oversight Need Improvement, GAO-13-130. Washington, D.C.: December 21, 2012.

Summary: Substance use and illicit drug use are a growing problem in the United States. SUDs occur when the recurrent use of alcohol or drugs causes significant impairment, such as health problems. The veteran population has been particularly at risk. Veterans are 1.5 times more likely to die from opioid overdose than the general population, according to VA and Centers for Disease Control and Prevention data. Furthermore, veterans live in rural areas at a higher rate than the general population, which may affect their ability to access SUD services. VA is the largest integrated health care system in the United States, providing care to about 6.2 million veterans. VA provides SUD services through outpatient, inpatient, and residential care settings and offers various treatment options, including individual and group therapy, medication-assisted treatment, and naloxone kits to reverse overdoses. Senate Report 115-130 included a provision for GAO to study VA's capabilities to treat veterans with SUDs. This report describes (1) trends in the number of and expenditures for veterans receiving SUD services, including specialty SUD services; and (2) any differences between veterans' use of SUD services in rural and urban areas, and the issues affecting access to those services in rural areas. GAO reviewed VA policies and data from fiscal years 2014 through 2018. GAO also interviewed officials from six VA health care systems, selected for their high percentage of veterans with an opioid use disorder and to achieve variation in geography and locations VA has designated as urban and rural. VA provided technical comments, which GAO incorporated as appropriate. The Department of Veterans Affairs (VA) treated 518,570 veterans diagnosed with a substance use disorder (SUD) in fiscal year 2018, a 9.5 percent increase since fiscal year 2016. Of these, 152,482 veterans received specialty SUD services in fiscal year 2018, a number that has remained relatively unchanged since fiscal year 2014. Specialty SUD services are those provided through a clinic or program dedicated to SUD treatment. Expenditures for VA's specialty SUD services increased from about $552 million in fiscal year 2014 to more than $600 million in fiscal year 2018. In the same year, VA expended about $80 million to purchase SUD services from non-VA community providers for more than 20,000 veterans, an increase since fiscal year 2014. The number receiving this care from non-VA providers may include veterans who also received services in VA facilities. Note: Specialty SUD services are those provided through a clinic or program dedicated to substance use disorder treatment. SUD services include services provided by any type of provider. VA data show that overall there was little difference in the percentage of veterans using SUD services, including specialty services, in rural and urban areas in fiscal year 2018. However, there were differences for some specific services. For example, in rural areas, 27 percent of veterans with an opioid use disorder received medication-assisted treatment—an approach that combines behavioral therapy and the use of medications—compared to 34 percent in urban areas. In providing SUD services in rural areas, VA faces issues similar to those faced by the general population, including lack of transportation. The agency is taking steps to address these issues, such as using local service organizations to transport veterans for treatment.