Transcripts For CSPAN3 Hearing On Prescription Management And Veteran Mental Health 20240622

All of the all of the dialogue here, and i think that whatever we have to know some facts first about how such a system would work and then where can you get those facts from . What . Where can you get those facts from . Well, first of all, for the care thats given, and by the way, pc3, if 80 of the veterans used the pc3 network of providers, it would solve a lot of your problem. But they dont. Very minute number currently use it for a lot of reasons. In any case you think thats the answer . That could be one of the answers here . Well, its one of the answers, certainly it is. It is. But for every other form of care, then have you this issue of whats f. A. R. Based and whether were doing this illegally or not. But the remedy has to be, once you know the answer to the question and get some clarity, not only on the accessible care issue, but also the cost, because i think that the impact on the Acquisition Workforce in va would be be potentially quite a bit more in terms of having to hire more people. But you have to get the answers first and i havent heard it here. Well, thats the problem at these hearings. A lot of questions are asked and very few answers actually are received. Thank you. I yield back. Can i follow on to your question, please . Mr. Chairman . Sure. So, i find myself in complete agreement with mr. Williamson, that we have to balance this need for access and provide the right structure that represents the interest of the taxpayer, so its balancing whats good for veterans and whats good for taxpayers. And to answer his question, how do we look at that to balance that, i own that for the department. Im going to work to put that together. I would love to meet with the committee and or staff as we do this and get your input, but have i to find a way that allows us to balance this, to meet the needs of the veteran, to manage their access while at the same time representing the interest of the taxpayer, and recognizing the federal acquisition regulations and all the appropriate laws. I own that for the department. Well, thank you for that offer. Well, id like to thank the witnesses. You are now excused. And let me just say, it really doesnt matter how the systems changed, because if youre not going to follow whatever systems there, because if you dont have the discipline, dont have the leadership, it really just doesnt matter. I mean, at the end of the day, theres got to be a rule of law. And this is just i think you, some of the Witnesses Today just, you know, really demonstrated how lawless this organization is. Youre now excused. Today we have had a chance to hear about problems that exist within the department of Veterans Affairs, with regard to oversight of its nonVa Health Care programs. This hearing was necessary to accomplish a number of items. Number one, to identify the continuing widespread problems with procurement of nonVa Health Care. Two, to allow va to provide answers as to why these problems still exist and have been allowed to continue for so long. And, three, to assess next steps that must be taken by the department in order to stem the continued waste of taxpayer dollars and jeopardized Services Provided to veterans. I ask unanimous consent that all members have five legislative days to revise remarks, without objection, so ordered. I would like to once again thank all of our witnesses and audience members for joining us at todays conversation. With that, this hearing is now adjourned. The cspan cities tour visits historic and literary cities across the nation every other weekend on cspan2s book tv and American History tv on cspan3. This month with congress on its summer recess, the cities tour is on cspan each day at 6 00 p. M. Eastern. More from Colorado Springs, colorado, today with a look at the citys literary life. Tonight on American History tv, programs about the presidency of richard nixon. Coming up at 8 00 eastern, Richard Nixons Foreign Policy with former members of president nixons National Security Council Staff about vietnam, the paris peace accord, and relations with china. At 9 50 p. M. , president nixon and the Supreme Court with a lecture in the Supreme Court chamber by Kevin Mcmahon author of nixons court his challenge to liberalism and consequences, introduced by justice antonin scalia. At 1035, president nixons defense secretary during the last years of the vietnam war and his strategy to position the military for the future. Mr. Hunt wrote the postvietnam military 1969 to 1973. Next, Veterans Health Administration Officials testify before a house veterans subcommittee about concerns over the heavy reliance on medication and the possible adverse effects of opioid therapy among veterans, including the risk of suicide. Good morning. This hearing will come to order. I want to welcome everyone to todays hearing titled prescription mismanagement and the risk of veteran suicide. Before we begin, i would like to ask unanimous consent that a statement from the American Legion be entered into the hearing record. Hearing no objection, so ordered. This hearing will examine the relationship between veterans prescribed medications as a result of their Mental Health and the increased suicide rate among veterans. Evidence uncovered by the o i subcommittee, gao examined vas data on veterans with major depressive disorder, including the extent to which they were described medications. The extent to which they were the extent to which they received proper care and whether va monitored that care and the information va requires vamcs to collect on veteran suicides. It is now clear that va is not even aware of the possibility of veterans with major depressive disorder due to inappropriate coding by va physicians. As a result, va cannot determine if veterans are receiving care consistent with the clinical practice guidelines. These guidelines are crucial to the treatment of mental disorders as they are designed to provide the maximum relief from the debilitating symptoms associated with Mental Health. It is imperative that our veterans receive the proper care and followup when receiving Mental Health care, especially when they are being prescribed various medications. What has also become clear is that va is receiving and reporting inaccurate and inconsistent data regarding veteran suicides. This severely impacts and lilts the departments ability to accurately evaluate its Suicide Prevention efforts and identify trends in veteran suicides. Not only did the committee conduct a hearing in 2010 on this same issue, but since then, there have been countless media stories of veterans being overmedicated or experiencing adverse drug reactions and not receiving the proper care. The proper followup or the proper monitoring, and the alltoo common result of suicide. One story told of a veteran who went into a hospital seeking care, but after being, quote unquote, lost in the system, ended up dying by suicide right in the facility. We will also hear other similarly tragic stories today that highlight the tremendous problems occurring within va for years and continuing today with regard to treatment of veterans with Mental Health. With Mental Health concerns, adequate oversight of treatment programs and, more importantly, the actions taken to ensure veterans who are prescribed countless medications receive proper followup. Currently, va has approximately ten different programs dealing with prescription medication. And Suicide Prevention issues. But it does not appear that any of these programs interact with one another. No one is talking to anyone else. How can we ensure that the veterans are getting the proper care, the proper followup and the proper advice if the right hand doesnt know what the left hand is doing . I think it is more appropriate to say, based on the statistics from the gao report and the numerous media stories that va is just throwing out a bunch of different ideas and programs, hoping one of them will stick. And they can claim they have solved the problem. This is unacceptable. We need to know exactly what va is doing to change this pattern and what is it doing to improve protection of veterans . What is the real way forward . Who will be held accountable for mistakes that have already been made and have cost veterans their lives . Who will stand up and take responsibility for making a change . It is time for answers. It is time for change. With that i now yield to Ranking Member kuster for any opening remarks she may have. Thank you, mr. Chairman, and good morning to our panel. Thank you for being with us. This morning we are addressing a complex Health Care Policy issue affecting veterans and over 100 million American Adults. The statistics on veterans experiencing chronic pain are staggering. Over 50 of all veterans enrolled in receiving care at va medical facilities experience chronic pain. With over half a million veterans managing pain with prescribed opioids. As a nation and certainly in my district and throughout the northeast, we face what can only be described as an opioid abuse epidemic. The centers for Disease Control and preskrengs has termed opioid abuse the worst drug addiction epidemic in the countrys history, killing more people than heroine and crack cocaine. In addition to the issue of Pain Management and the problems of addiction, we must remember that many veterans who experience chronic pain also suffer from Mental Health disorders, such as postTraumatic Stress and traumatic brain injury. Therefore, it is vital that the va has in place the proper oversite mechanisms to monitor the safe use of opioids for managing veterans pain. I am particularly concerned about veterans at risk of selfmedication and addiction being prescribed opioids for Pain Management. We know from multiple Inspector General and gao reports that the va has struggled to properly monitor prescribed opioids and Mental Health of its patients. Im concerned a potentially deadly mix of opioid use, Mental Health disorders and lack of oversight is contributing to our high rate of veteran suicide. The newest Drug Enforcement Agency Regulations that require veterans to see a clinician monthly for a refill of Opioid Pain Medication creates an additional burden on veterans who have difficulty accessing care at va medical facilities, leaving some veterans to suffer from extreme pain and experience Opioid Withdrawal symptoms when theyre unable to schedule an appointment to refill. This hearing provides us with the opportunity to begin to seriously examine whether the benefits of managing veterans pain with opioids is outweighed by the risk and side effects experienced by veterans and the Va Health Care system struggled to properly monitor opioid use. During this hearing, i would like to hear from our witnesses how we can better address safe and effective treatment of veterans while ensuring that Care Management is not forgotten. Id like to discuss whether a higher level of informed consent is needed to ensure veterans and their families understand the risks and side effects before choosing to manage pain with opioids. And whether the va is properly coordinating Mental Health and Suicide Prevention programs with wa medical care facility nurses and clin i guesses responsible for monitoring patient opioid use. Im also interested in alternative Pain Management and whether as i get to my comments lashgts ill discuss whats happening at the White River Junction va in bringing down the rate of opioid prescriptions and how we can help get ourselves out of this problem, out of this cycle and address the veterans to serve their needs without putting them and their families at risk. Finally, i would like to discuss what is being done to reduce longterm opioid use and treat the underlying conditions causing chronic pains, so that veterans are able to live a better quality of life. Thank you, mr. Chairman. And i yield back the balance of my time. Thank you, Ranking Member kuchlt ster. I will introduce our witnesses in one moment. I ask the witnesses stand and raise their right hand. Do you slemly swear under penalty of perjury that the testimony you are about to provide is the truth, the whole truth and nothing but the truth . Please be seated. I would like to recognize the honorable jeff miller, chairman of the full Veterans Affairs committee who has joined us. Thank you, mr. Chairman. You have the floor. Thank you, mr. Chairman, Ranking Member ms. Kuster, thank you for the work this subcommittee has been doing over the last several years. If i might, instead of giving a typical opening statement, i want to ask ms. Clancy a couple questions because i need to move on to another appointment. And i believe, dr. Clancy, you have been made aware that i am going to be asking a couple of questions, albeit a little bit out of order. And i want to talk specifically about bradley stone, that we know that he was seen by his va psychiatrist a week prior to his commission of multiple murders and subsequently dying of suicide. He was on many, many Prescription Drugs and had alerted va, as i understand it, to Mental Health and physical difficulties in the weeks leading up to the incident, but it appears that va said he showed no sign of suicidal or or homicidal ideation. And id like to know how how did va come to that conclusion when that the veteran was okay, and i say that in quotes, when he was reporting all of these feelings prior to the incident. In general, people would come to that conclusion by asking the veteran a series of questions about were they having thoughts of harming themselves and so forth to get some assessment of suicide risk. So, my conclusion, if the clinician said would be that the veteran answered gave negative responses to that. Okay. On the 24th of april of this year, i asked the department if it would confirm whether or not that they had provided the full committee with all of the files related to bradley stone. To date i have not received a response, so, again, i ask you, has va provided this committee with all of the files on bradley stone . I had been told that the va had provided the committee with the files with some redactions and had also provided offered an incamera review and the redactions were about Social Security numbers and some information that was about sensitive details about the living family members of bradley stone and, again, offered to discuss that with the committee in camera. And, again, as i have stated in every single letter that i have sent to the department requesting information, an incamera review is not acceptable. That may be what you want to provide us, but that is not at all acceptable. And so, you know, the staff is informed you and the department that i was going to ask particular questions, so, again, i ask you, has all of the information and i would go back to i sent the secretary a letter on april 24th, where i referred to ms. Diana reubens, director of the Regional Office on april 22nd, saying that the philadelphia Regional Office had provided everything related to mr. Stones file. Her response was, unequivocally, yes. So, i am taking from your comment today, then, everything that she provided to the Central Office, the Central Office has now provided to this committee . Since im under oath, im going to be very careful. I cant speak for what diana reubens is telling you. I have been informed directly by our lawyers that we have provided this committee with all the records with the redactions that i mentioned before. Again, Social Security numbers and some sensitive details about the living family members of mr. Stone. Okay. I want to, for the record, mr. Chairman, and dr. Clancy, i know for a fact that va has withheld hundreds of pages related to the bradley stone file. And so, with that, i would say that we have requested all the documents every way we know how. So, ill ask you one more time, can i expect the department to deliver the complete records by the end of this week . I will take that back and i will verify what ive been told, that we have given this Committee Everything except for redactions as i noted earlier. Okay. I can assure assure you it is redacted, it is missing. Completely missing. I will bring that message back. We also expect you to deliver the bee haporal Behavioral Health autopsy redacted by the end of the week. And i will reiterate, a incamera review is not acceptable and i ask if you will commit that all of the documents that ive requested about be provided by the end of the week. The Behavioral Health autopsy is a unique feature at v. A. Health care for veterans. Rather than having a private limited to the people at the facility, route cause analysis or deep dive of what happened when a veteran takes his or her own life, this is something that we have centralized so we can learn across the system what kinds of factors might have precipitated the suicide, what could we have done differently or better and it also involves a conversation with the family members of that veteran. None of whom have been told that we would be thoughtfully sharing their details with members of the committee. And we think it will have a Chilling Effect on family members sharing sensitive details and are very, very count very uncomfortable with sharing that. Thank you for that opportunity. I rememb i remember we are the executive branch and you are the Judicial Branch and we have anything done in your department that you choose to withhold, well subpoena it if necessary. Can i expect to have this information delivered by friday . Ly take that back, mr. Chairman. And also i would like to add on a positive note, i was in cincinnati yesterday, i was in dayton the day before and i want that thank you for the facilities there and there is a specifics and i enjoyed spending a couple of hours with the people in cincinnati. We do focus on a lot of the negative. And the press likes to focus on that as well. But i want to commend you on the some of the great things and i would hope that some of the good things at cincinnati would be shared throughout vha and the rest of the department. Thank you very much. If i might, for one second, mr. Chairman, thank you very much for that. I know how hard those people work. Cincinnati is actually the hub of expertise in intensive care for our system so they actually provide remote assistance i had a chance to view it. Did you . It is great. It really it. Thank you very much. Mr. Chairman, one point, dr. Clancy, the v. A. Has turned over Behavioral Health autopsies to this committee before. And so Ranking Member kuster . I wanted to say for the record as a Health Care Attorney who has worked in this area for quite a long period of time in the realm of Quality Assurance and what the purpose of this type of Quality Assurance is about when you go back and look, it is intended for physicians and the medical team to grow and learn from these experiences. And im just concerned at the impression that might be left with veterans and their families, particularly the family members through the trauma of a suicide, that this information would be treated confidentially. And these hearings as we know are televised and a public setting and i think we should get to the bottom but i dont want to do anything to have a Chilling Effect on families that are sharing the most personal aspects. We already have such a strong sigma around Mental Health and about people seeking treatment and i would be extremely concerned if we left the impression today that we are in some way digging into private affairs. If there is information about living family members that is not relevant, it could be extremely personal. And i guess i just dont understand why we copt do that in a in a private setting or in a redacted way, why this committee would be trying to determine and im not speaking if you believe there are documents not provided, that is a separate matter, but i know that under our statues in the state, confidential information in this Quality Assurance process is confidential and not to be shared an the purpose of that is so people will come forward. That is my only comment. Thank you very much. And i appreciate the expertise you bring to this committee and to this subcommittee. And you can rest assured and i think you know that what were trying to do is to hold people accountable. We are not trying to release any information that is personally identifiable. This is also a murder situation. It is a suicide which is very difficult but a murdersuicide. And so i believe that while the v. A. Is going through and doing this and attempting to find out where things may have broken down, the fact is we have gotten this information before, from other incidents. This one is particularly grievous because of the murders that took place. And i would remind you that we are a federal body, not a state body. Were bound by the United States constitution of which we are given oversight of the executive branch and we are not bound by many of the laws the hippa laws and other information to receive that for us to do our oversight in this and this is not political. Again, we are trying to get to the bottom of a very tragic event and were trying to partner with the v. A. As well. And right now, they are not being as open as they should be. There are documents that are clearly missing from the file. Documents that i believe are damning documents and would put v. A. In a very negative light. I understand that. But you cant remove those documents from the file just because it makes you look bad. And that is what were trying to get at at this point again. Again, i thank every member of the subcommittee for the job you are doing and look forward to continuing the good works. Thank you, mr. Chairman. I ask others waive their opening remarks as per the committee custom. With hearing no objection, it is so ordered. Would you like to now introduce our panel. On the panel we have dr. Carolyn clancy, interim undersecretary for health for the department of Veterans Affairs. Mr. Michael michael valentino, chief consultant, pharmacy benefits, Veterans Health administration. Harold kudler, chief consultant, Veterans Health administration. Mr. Randall williamson, director of g sav o healthcare team. And dr. Jacqueline maffucci, Research Director for the iraq and afghanistan veterans of america. Dr. Clancy, you are now recognized for five minutes. Good morning, mr. Chairman, ram custer, members of the committee, thank you for the opportunity to discuss the overuse of medication and the provision of Mental Health care to veterans, particularly for those at risk of suicide. One of the most important priorities at v. A. Is to keep our veteran patients free from harm at all times. Im deeply saddened by the tragic out come involving a veteran, so to families here today or watching who lost a loved one, i want to express my sorrow and regret for your loss. I appreciate your sharing your experiences with us and we will honor your loved ones by learning from those experiences and improving care for veterans in the future. We acknowledge up front that we have more work to do to reduce opioid use and meet the demands for Mental Health and suicides and taken significant actions to improve the areas in order to better serve veterans. As Ranking Member kuster said, chronic pain is a National Public Health Problem effecting about a third of the nations Adult Population and about half of veterans from recent conflicts. As a result, a number of veterans and americans rely on opioids for pain control and they can be effective for a while until the side effects become quite worrisome and often mixed with other drugs that can have additional adverse unintended effects. As you noted, mr. Chairman, weve adopted a number of initiatives and tools to advance our goal of safe and effective Pain Management, making data about rates and doses of opioids as well as the other medications a veteran is taking visible at the Network Facility and most recently at the individual clinitian level starting this july 1st we are expanding on a successful pilot, an approach called academic detailing which essentially consists of oneonone coaching for every single clinitian prescribers in our system. In addition to information about effective use of medications, it also this approach also works with clinitians to have the Difficult Conversations with veterans to help them try other alternatives to Pain Management and so forth. I think it is important to note that many of the veterans we serve come to us as they are transitioning from military service on opioids and other medications and abrupt discontinuation is not possible or actually practical. But we have to continue to taper these doses. Weve seen some successes and you might expect those with the least amount of problems have tended to do better than those who are experiencing more severe pain. Suicide among veterans is very complex and tragic. Those of us who have lost a loved one to suicide know the deep and lasting pain. Weve worked diligently with our scientific partners to understand suicides among veterans receiving v. A. Care and veterans across the nation. We know that treatment works. Weve identified many positive out comes for veterans who are receiving our care. For example, the rate of repeat attempts at suicide among veterans who have attempted to take their own lives has declined quite a bit for veterans enrolled in our system. Between 1999 and 2010, the suicide rate among middle age veterans who use our system fell by 31 at the same time that the suicide rate for middle age men who are not veterans or dont use our system actually rose during that time period. The rate of suicide among Women Veterans is higher than other women in the general public. But Women Veterans who use our system are less likely to die from suicide when compared to other Women Veterans. As you know, our research has allowed us to estimate that about 22 veterans die by suicide every day. What is less wellknown is that 17 of the 22 do not receive treatment for care within the v. A. System and i worry that some of the 17 are actually seen in our system and are fearful about raising Mental Health concerns because of concerns about stigma or privacy. Suicide prevention efforts have to extend to veterans who may not seek assistance. And any veteran who needs help can come to any point of entry and care in our system and will be seen that day. Weve also increased targeted outreach efforts to veterans throughout the country and made it easier for those who call the Veterans Crisis line. In response to many suggestions from stakeholders in the very near future, you can do that when you call one of our facilities directly. You wont have to hang up and call the line. You can just hit a number on the phone and that will directly transfer you. I want to express my appreciation to the congress fo the clay for the clay hunt act to expand our help to veterans, so thank you for that. The importance of Mental Health cannot be overstated. About 20 years ago in this country, we did not recognize how important a challenge Mental Health care is for all americans. At v. A. We have embraced the problems that veterans from returning conflicts brought to us, whether thats various Mental Health problems, post Traumatic Stress and traumatic brain injuries and so forth and in doing so weve had to blaze some trails. We have to go ahead of what is going on in the rest of u. S. Health care where the utilization of Mental Health has been curtailed. Utilization controlled over the years. That meant we had to work with public and private partners to build the epidemy logical data and expertise. Weve learned a lot and seen successes in treating Mental Health problems but we have so much to do to dispel the link to Mental Health issues. And it wasnt long ago that cancer and the whispering due to fears and misinformation and we hope that soon we can eliminate that fear and misinformation associated with seeking Mental Healthcare and in the meantime were focusing on creating an atmosphere of trust and privacy. I want to just close by saying were committed to improving the existing programs and taking every available action to create new opportunities and most importantly improving the quality of life for veterans. Were compassionately committed to serve those who have served. Were proud to have this honor and privilege. And were prepared to answer your questions and look forward to working with you until we get this right. Thank you. Thank you, dr. Clancy. Mr. Williamson, you are now recognized for five minutes. Good morning, mr. Chairman and Ranking Member kuster. Im pleased to be here today to discuss our november 2014 report on vha efforts to monitor veterans with major depressive disorder, referred to as mdd. Who were prescribed one or more antidepressants. Mdd is a risk factor among suicide among veterans. It is a Mental Illness associated with severe depression and reduced quality of life. Also i will discuss certain aspects of the vha Suicide Prevention program. Specifically i will discuss the incidents of mdd among veterans treated by v. A. , the extent that v. A. Clinitians prescribe prescriptions and monitor use and collecting and reporting on veteran suicides to inform the Suicide Prevention efforts. Vha data show 10 of the veterans receiving health care were diagnosed with mdd and 94 of the veterans with mdd were prescribed one or more antidepressants. But the estimate may be low because in reviewing a sample of medical records of mcs we found that the v. A. Did not always correctly report and record confirmed mdd diagnosis among veterans. At six v. A. Mcs we reviewed a sample of veterans with mdd prescribed one or more antidepressants and they did not receive recommended care for three important recommendations in the clinical practice guideline referred to as cpg to guide the clinitians in treating mdd. For example, although the cpg recommends that a veterans depressive symptoms be assessed using a standardized Assessment Tool at four to six weeks after initiation of antidepressant treatment, we found that 26 for the 30 veterans in our sample, v. A. Clinitians did not use this Assessment Tool at all or use it with within a specified time frame. While not mandatory for v. A. Mc clinitians, the cpg recommendations are on evidence based data on research and trials and other proven and reliable sources and are meant to enhance out comes for veterans with mdd. Moreover vha does not have a process to monitor the extent that the clinitians deviate from cvg recommendations. With little if any visibility over whether the care provided is consistent with the cpg, v. A. Is unable to ensure that recommendations are identified and evaluated and whether appropriate actions with taken to mitigation significant risk to veterans. Finally, we found that demographic and Clinical Data in v. A. s collection on suicides to better inform the Suicide Prevention program were often incomplete and inaccurate. For example, as part of v. A. Behavioral Autopsy Program which i refer to as v happ, we have number of Health Visits and date of death and last v. A. Contact. We investigated three reports from mcs and twothirds contained inaccurate and incomplete information. This is further exacerbated because vhap reports are not reviewed at any level within vha for accuracy, completeness or consistency. Lack of accurate and complete data limit opportunities to learn from past veteran suicides and diminish efforts to develop effective methods and approaches to enhance and reduce veteran suicides. The v. A. Has made Good Progress in addressing the six recommendations to improve weaknesses we reported in our report. In the six months since the report was issued, one recommendation has been fully implemented and several others are fully close to being implemented. This work illustrated once again a continuing pattern of the vha unclear guidance and poor oversight. These were the same factor that led gao to include v. A. On the high risk list. Until v. A. Instills a culture through the organization that holds the staff and managers accountable for overseeing out comes and achieving a recognized standard of excellence, the v. A. Will continue to fall short of providing the highest quality and Cost Effective care to our nations veterans. This concludes my opening remarks. Thank you mr. Williamson for your remarks. Dr. Maffucci, did i say that right . Yes, you did. Thank you. Thank you. You are now recognized for five minutes. Chairman kaufman and Ranking Member kuster and the members of the subcommittee, on behalf of the veterans of america and our nearly 400,000 members and supporters thank you for the opportunity to share our views and recommendations on prescription management and the potential risk of veteran suicide. In 2014 iva launched a campaign to combat suicide. With your help we signed the clay hunt save act into law. That thwas the first step to address the challenges of combatting suicide among our Service Members and veterans. The issue that were here to talk about today is complex because it encampused two topics. Providing care for veterans seeking relief from chronic pain, mental injuries and other conditions and recognizing the potential for misuse and abuse of these powerful drugs. And while the drugs are extremely powerful, they can also be extremely effective for a veteran who has not found relief elsewhere. Chronic pain effects 100 million American Adults and this number is growing. Given the last 14 years of conflict and the daily demands on our troops weve seen a similar trend among Service Members and veterans. Over 60 of the iraq and afghanistan veterans seeking v. A. Medical care seek care for musculoskeletal elements and this is the most common for disability compensation. 60 seek care for mental injuries. Within the community, two out of three responded to our survey receiving chronic pain and one in five reported using prescription opioid medicationed and one in three using antianxiety or antidepressive medications. Medical advancements have allowed for higher survival rates from complex injuries but increasing the need for nerve and skeletal management. Pain can be more complex because other conditions like depression, anxiety, ptsd or tdi may limit options. For clinitians, assessing pain can be very difficult as well. Particularly given that knowledge in this field is still growing. Primary care physicians who see the bulk of patients with chronic pain report they feel underprepared to treat the patients due to lack of training. This including vha providers surveyed in 2013. Untreated pain can put an individual at higher risk for suicide. And yet we also know that Prescription Medications can result in strong additions and provide a means for suicide attempts. The v. A. Reports that over half of all nonfatal suicide attempts results from overdose or intensional poisoning. This highlights the challenges that clinitians face and demonstrates the importance of comprehensive intergrated Pain Management. While the v. A. Has moved the needle forward investing in research on pain and publishing a guideline, implementing an Opioid Safety Initiative and inducing a stepped base management system, more remains to be done. With approximately 22 veterans dying by suicide every day and more attempting suicide, reducing instances of overmedication and limiting access to powerful Prescription Medications must be included in addressing this issue. A recent study showed those receiving opioid therapy are at risk for suicide, the guidelines could reduce this significantly. This shows the need for the guidelines but full implementation of the guidelines. The v. A. 2009 directive on Pain Management skpared in october of 2014. While it expired in date only and the policy remains active, iva discourage that updating this important policy has not been prioritized. We urge the v. A. To implement it at all v. A. Facilities. We would like to emphasize the importance of the risk of overdose and overmedication through take back programs and Prescription Drug monitoring programs. Last year a important change expanded authorization tor drug dropoff sites. This change gave the v. A. The ability to stand up drug takeback programs in the hospitals and this is critical to limiting the misuse of powerful Prescription Drugs yet no action has been taken. And while the v. A. Is working to fully implement the participation in state Prescription Drug monitoring programs, full implementation remains to be seen and we urge the v. A. To prioritize this as well. Too often we hear the stories of veterans prescribed what seems like an assortment of antipsychotic drugs or opioids with very little oversight or follow up and we hear stories of veterans with enormous pain and doctors who wont consider their requested for request to manage their pain. These are tough challenges and we remain committed to work with the v. A. And congress to address them. Again thank you for the opportunity to offer our views on this important topic. We look forward to continuing to work with each of you, your staff and this committee in this critical year ahead. Thank you for your time and attention. Thank you, doctor, i deeply appreciate your testimony. Whos next . Okay. All right, thanks to the witnesses. Now dr. Clabsy, according to a gao report, v. A. Deviated from recommended guidelines in most all of the 30 veterans cases reviewed by not assessing antidepressant treatment proper properly. In your opinion, is policy ignored or is there a lack of oversight by leadership. So first i want to say that we regard the gao recommendations feedback very important, a gift to help us get better. Im not sure any guideline written on planet earth should be followed 100 of the time. Many doctors think of them as tools, not rules because there will be patients with unique circumstances that dont fit perfectly. In terms of the followup assessment, i think that is important and we need to do a better job. We are looking to see whether that is a feature of the fact that we had were having access problems and hard to get people back in or whether we werent just on the ball. But this is a very important feature. Dr. Clancy, in the case reviews we found veterans that died of drug toxicity who reported hallucinations and died by suicide and reported homicidal thoughts. Are these the improved outcomes you are referred to. No, they are not, mr. Chairman. Dr. Clancy, in response to the gao report, the v. A. Noted it would conduct chart reviews and develop a plan to determine and address the factors attributed to codeine variances, to be completed by march, 2015, has this been completed . It is in progress. We are not completed yet. I will also add to that, that in addition to that i have been meeting inspired by the gao report and other feedback with dr. Kudler and the other national Mental Health leaders in our system to figure out who have the veterans who we think are struggling the most with Mental Health disorders that we should be targeting to make sure they are getting the best possible care. Thank you, doctor. When do you think that report will be done . I have to double check on when we committed to have the recommendations done. Okay. Our v. A. Stated it would examine associations between treatment practices and indicators of recovery or adverse out comes for veterans being treated with antidepressants, the target date of completion was also march 2015, has this been completed . I believe that it has. I have to double check my notes here. Here we are. Can you get a copy of it to me. Yes. Absolutely. Well submit that. Roughly 63 of the Behavioral Health autopsies reviewed by goov, Critical Data was missing. Is this inaccurate reporting based on incompetence or is it to intentionally keep Central Office in the dark . I have no reason whatsoever to suspect it is to keep Central Office in the dark. As i understand it, this program was transitioned from doing root cause analysis at individual facilities to a centralized repository two years ago and as you might expect training reviewers and people doing the interviews and collecting the data to collect that data consistently and accurately took some time and frankly some iteration to make sure that we were getting it right. Dr. Kudler, do you want to add to that . Yes. At the time pardon me. At the time the g was conducting this study, the program was just being launched. The forms were new and in need of refinement and they have been continuously refined as has the training of the Suicide Prevention coordinators, at over 150 facilities that fill them out. There were questions about what data goes where and how do you address this or that and that is now assessed in the training and the manuals. We are addressing these. And we have software that crosswalks these two and other Suicide Prevention the span system, to make sure we are looking at these from multiple perspectives so this is continuing and progressed since the report and well continue to work on this. Dr. Clancy, we have requested autopsies for numerous veterans who have died by suicide and in all cases except one of cleesha holmes, the v. A. Has stated this information is confidential and priv lentiled and it cannot be released to us. If this is true, why was the report for miss holmes released to the committee . I would have to take that question for the record. I would say in general the Behavioral Health autopsy reports, i think the Ranking Member kuster described this more clearly than i could, this is part of Quality Assurance where you want the most forth right kind of input and observations and if people think this is going to be disclosed well not get input that is that forth right. Well i think were concerned about the fate of our veterans and this subcommittee and the committee as a hole has a responsibility oversight responsibility for your operation and we cant do that over site operation in making policy best for our veterans if you dont fulfill your obligation and submit that information when requested to the congress. Um, Ranking Member kuster. Thank you very much, mr. Chair and thank you to all of v particularly dr. Maffucci, i appreciate you being here and sharing with us the recent experience of the veterans returning from, as you mentioned, 14 years of conflict and that the injuries are much more complex. The good news is people are surviving the difficulties, as you say, they have chronic life long issues. I want to focus in on how we move forward. I share the concerns that have been expressed about the data and making sure that we are getting at the heart of the issue here. But im very interested, as i mentioned, i had a meeting with the team up at the White River Junction facility and there is some cuttingedge research and ill talk to the chair about bringing in witnesses to share that. But in particular, the Opioid Safety Initiative, and a couple of Different Things and whichever is the appropriate witness, one is getting at the heart of what is causing the pain. Ive lived with my husband has chronic pain and many, many years of back pain and various medications and come to find out what he needed was a hip replacement. It wasnt about his back at all. And now he lives painfree, with yoga and stretching and exercise and such. So id like to find out what is being done to get at the crux of what is causing the pain. Secondly, setting a goal of reducing opioid use and working with practitioners to bring down the opioid use. And particularly emphasizing patient education and close monitoring. They talked about actual drug testing because in our area, selling the opioids on the market, what happens is people will not use the medication themself and they can determine that through frequent drug testing, which, as you can imagine, is not pap lar with the patients. But unnecessary. And then alternative medicine, acupuncture, i mentioned yoga, massage and exercise. If you could comment on the Opioid Safety Initiative and how far has that gone and how widely has that been and is it in use and what can we do to move that forward. Thank you. Those are all terrific questions. Im going to start and turn to mr. Valentino. Like with depression, we do have a clinical practice guideline we developed from the colleagues from the department of defense on the management of chronic pain published in 2010 and as of september of this year it will be updated which is about the frequency you want to update the guidelines and well be having input from veterans and family members. The guideline does include urine drug testing periodically and we have, as i mentioned, probably too quickly in my opening statement, made in a series of steps that i the umbrella of which i would refer to as the Opioid Safety Initiative made data about prescribing patterns at the network level, the facility level and most recently at the individual clinitian level available and visible. So that clinitians can actually see what has this patient been on over time and what other drugs are they on and so forth. Getting to the root of the problem, i think is incredibly important. Would you be happy to submit to the record and brief anyone any time about some of the Exciting Research we have in process because i think it is very important. I think there is a lot we need to learn in two areas. One is what are the predictors of veterans or anyone who is likely to use opioids for a short time and go down the path of using them on a regular basis. Because if we knew then, that is where we could target a lot of efforts. And the second is which veterans are more likely to respond to treatments to nonnarcotic medications and so forth. As i said, we have some Research Going on in that area and have a lot more to learn. Mike, do you want to add to that . Yes, thank you. So the Opioid Safety Program is just shy of two years old. And weve had to build it from the ground up. And as dr. Clancy mentioned, it has been veritieraive. We focused on this Data Collection and allegation to identify potential outlier visions and we focused on that as for corrective action plans. The next was to focus on visions but drill down to v. A. Facilities which he we did identify out liars and we know this is working because 17 medical centers identified have fallen off the list. We are poised right now at this moment and we built the tools and were validating them for accuracy to drill down to the individual provider and patient level. This is very complex as you might suggest. Someone might show up as an out liar but maybe they are a pain specialist or treat cancer or other so we have to shake sure we get it right so there is confidence in the tool. But weve had really, really good results. Ill just name and go through some of the metrics. Since we began we have 110,000 fewer patients receiving any kind of opioid shortterm or longterm. 34,000 fewer patients receiving opioids and benzo die asa pines together. That is a known risk. 75,000 more have had a urine drug screen because that is definitely an opportunity for diversion and we want to make sure patients are taking it. We have 92,000 fewer patients on longterm opioid therapy which we define as longer than 90 days. We also have begun to look at the totality of the opioid burden. So there are many opioid drugs but you have to sort of boil those down to a common denemmonator and im sorry my time is up. Im very interested in what you have to say but my colleagues need their turn as well. So thank you so much and we can take that on the record. Mr. Lamborn in colorado. And lets see if we cannot run the clock out on some of the answers. Well i would like to thank the chairman for bringing the important issue to light. Unfortunately it comes to late for one of my Colorado Springs families. I would like to tell you the story of noah, a former marine who served in 2009 and in afghanistan in 2011. I wont use his last name but the parents have authorized the use of his picture so if i could show you knowas picture. He begin on a business degree at Colorado Springs and started his Online Business based out of Colorado Springs. Noah comes from a military family. His dad having honorably served for 23 years. Noah chose to put off college to serve this great nation. Unfortunately his parents are appalled by the care that their son didnt receive from the v. A. They believe their son would still be alive had he received better care. Noah was diagnosed with ptsd and received a 50 disability due to ptsd. On april 2nd of this year he went to the Colorado Springs v. A. Clinic where medical notes from his visit state that he had suicidal thoughts or Suicidal Ideation specifically. Noah was prescribed a psychotrophic drug ven la faxine and sent on his way. We dont know what this drug did or didnt do. But we know he was not preferred for Suicide Prevention and not offered counseling and no followup from the v. A. He went missing may 4th and was found may 12th of this year dead from suicide, a month ago. The family is devastated. They are asking a lot of serious questions. And dr. Clancy i would like to ask you several questions on their behalf. Why was their son who had been documented with halving suicidal thoughts or ideation not referred to Suicide Prevention. Why wasnt there a follow up from the v. A. And why wasnt he offered counseling . I will look into this personally, mr. Congressman. That is heartbreaking. I cant even imagine i can imagine but i know it is horrendous what his family is going through. The picture was worth many, many words, someone who did so much for this country and i will look into that and get back to you on this and to the family. Would one of the other witnesses have any response to my questions, to the familys questions . As a psychiatrist, as somebody who has treated veterans in clinics for 30 years, it is hard to understand the report that were given. And yet these seem to be the facts that have available and we have to look into it. I want to make sure the family has been reached out to directly and we have a chance to collect the information. As i say, we created a system. It can be cold and inhuman and we have to sit down and understand everything that happened from their point of view and sit down with them, which may torture them, and well work to deal with that. Thank you mr. Chairman and i thank you for having this hearing and i yield back the balance of my time. Mr. Oroke, texas. Thank you. Dr. Clancy, a question to which i would like to receive a quick direct answer. Were touting reduced prescriptions of opioids as though perhaps that in itself is success. What i would like to know are the consequences. I have veterans who show up to my town Hall Meetings saying prescriptions were cutoff without notice or transition or ramping down. How many of those no longer prescriptions are now using heroin or other street drugs . We cant know that without with the information that we have. It is something we worry about constantly. Let me tell you another problem. This is hopefully helpful feedback from el paso. Others who have prescriptions are required to renew them after a monthly visit with the prescriber. They are unable to get the appointment in el paso to see the prescriber so they cannot get the prescription renews and they do with something they buy on the street and at a minimum they are suffering and i would sect that to the suicides we see in el paso. I would also like to give you the following feedback. As i shared with you and met with you on monday, the may 15th access report from the v. A. Shows that el paso is ranked 157th out of 158 for Mental Health care access. We have 115 physicians approved for el paso and only 87 are filled leaving a 24 vacancy rate. Your predecessor, when we would relay anecdotal information that i was hearing from veterans told me we were seeing everybody within 14 days. We did our own survey and found more than onethird of veterans could not get a Mental Health care appointment, not within 14 days or a month or ever. Because we are surveying again and receiving the responses back and that has not improved in the year that weve had new leadership there. This should be for you a fivealarm fire. I have met with the widows and mothers of suicides in el paso far too often and im continuing to do that and i just did the last time i was home in el paso. As you know, for whatever reason, the v. A. Has been unable to resolve this issue and it turn it around. Im gad to hear there are good things happening in other parts of the country but everything i do is for the veteranize serve in el paso. You know we have a proposal from the community to address this. I want your commitment that you will work with us because the community has come forward in the vacuum of leadership in will and resources to do the right thing. I will do whatever it takes to work with you and your team and the secretary to get this implemented but this is a crisis that haseadly repercussions for the veterans that we all serve in el paso. And i want to make sure because we didnt take it seriously over the last year because the statistics and vacancy relative to Mental Health is worse than a year ago. I want your commitment that you will work with me to solve this and this is a crisis for you and it is urgent for you and we will turn this around. You have my full unwaivering commitment. We were impressed with you reaching out and bringing in members of the El Paso Community to work with us and i want to thank you for your support of our employees during what was a different kind of tragedy at the el paso facility several months ago. Something that cut to the heart of clinitians across the country but particularly to those serving veterans in el paso. You have my full commitment. Thank you. I yield back. That is not enough. These veterans have been here over and over and keep being told that you are committed. Weve seen nothing. You cant even have [ inaudible ]. Sir. Youre out of order. Youre out of order. Thank you. Dr. Benishek, you may begin. Thank you, mr. Chairman. I want to associate myself with the comments of mr. Orourke for one thing and that is ive seen this as well, is that the goal seems to be cutting down the amount of narcotics, and the same circumstances happened in my district too where people have had prescriptions cut off with no alternative treatment. Figure it out. It has been a real problem. A couple of specifics i want to get to after that. And that is something dr. Kudler said and then something mr. Williamson said. And mr. Williamson said there is not that much not that much followup on this Behavioral Health autopsy rowe gram or learning anything for it. Can you remind me what you said in your testimony because it is contradicting what dr. Kudler said. We were talking about very little oversight at the local or nationalal level to see whether it is accurate or complete. Dr. Cudler you said you are doing over site and the g. O. Says you are not. What is going on. The difference is the two years since the report was written. Im not questioning the report. In fact it is helpful as a spur to do more. At this point were making a real difference in can you show me the result of the over site youve done in the last two years. Can you get that to me in a reasonable period of time . Like within a month. That is not the way it is. To respond to our recommendations on oversight, i dont think v. A. Has completed those yet. It is not the two or three year lag at all. I think what were talking about there have been some some changes made. There is a box checked on the behavioral autopsy report that indicates that over site has been done. That is all there is, is it box. Well that is one of the things and they are revising and guidelines and they are making progress but it has not been completed to our understanding. I will give you another chance, im sorry, but dr. Clancy, you said something in your testimony that was very important to me and that is this seems so simple but the fact is that people have an idea they want to hurt themselves have to hang up and dial another 800 number when calling into the v. A. And you spontaneously said you will have that mixed and just hit a key and make that work. So, what i want to know is when . Can you give me a date when you that will happen and i can call the number and see if it is working. When will that happen in. Absolutely. By november or december. One of the things that we have been working very closely with the Veterans Crisis great. We just want to make sure we dont overstress that system when we do it. I just want a date so if it is not there by november or december. Yes. Because i agree with the guy that stood up here in the back and was out of order in that it is this it is great to hear that you are all going to do work, but from where i sit, the actual accomplishment of the job does not seem to be happening. So just no, i hear that. Ill be back to talk to you in january and hopefully ive called those places and there is actually a number i can hit because i got people calling me all of the time, this is ridiculou ridiculous. I will be checking. But yes. With that, i yield back the remainder of my time. Thank you mr. Chairman. Thank you dr. Benishek. Mr. Walz of minnesota. Thank you to the chairman and thank you all for being here today. And i too would like to hit on this, the osi implemented in minneapolis and we followed this closely since october of 2013 and were getting the results but my colleagues, and i would associate with them and this is nothing new to you that we saw dramatic increases in calls after it was implemented which is somewhat expected but i think the lack of maybe being there or the alternative and i say this very clear, this issue of Mental Health parody, this Mental Health treatment is societywide. This is a first step on clay hunt. But it is a broader issue. And on the opioid issue this nation has vacillated to overprescribing and underprescribing as the Research Gets it. And so i hear that. And my concern and frustration and you hear frustration from veterans whether it be here or all of the time, this Pain Management thing is a tough one. Tough, tough, tough. I represent the mayo clinic area so these are folks dealing with this also on a very big issue but i was proud back in 2008, one of the first bills i was able to move through was the veterans paying care act and out of that came the pain directive 2009053. And we put together through iom, the step care pain model which is the gold standard. Is that correct . Yes. And i wont go through all of it that is here, but what i would say is that it had a fiveyear span on it. I wanted to go further but this is the nature of how we do legislation. It expired in 2014 before it was fully implemented. It did not get reauthorized. But when we were out in toma on this issue, dr. Clancy, and you responded, on march 30th, that the v. A. Doesnt need us to do it and you can put it in yourself and i said this is wonderful and lets do it and i followed up with a written letter and i dont expect to be a High Maintenance person but ive heard nothing on my specific question. So the frustration lies in this was seven years ago we were dealing with Pain Management and seven years ago we implemented best practices and seven years ago the v. A. Started but didnt fully implement and eight months ago it expired and three months ago i asked about it. And i hate this exchanges that we continue to have. I hate the pattern of communication that we now have because it does not bode well for veterans and it does not fit and in fact it is very irritating. And i dont set you up because i wanted to start and preface this that i understand the challenge of this and understand the deep societial issues and understand the positives were making and the plus and minuses but the frustration is this might not have been the fix but why arent we done and why arent we. It is still being donin done initially and we have to get better in updating our policies and directives but the pain process has been updated who knows that . Would the author of the bill know that. Were going to tell you as soon as we made sure we got consensus and didnt miss any details. I apologize, i have not personally seen your letter but i will make sure i do see it before the day is over. And part of this, and again i dont expect to be High Maintenance and you have other issues and our job is tasked to do that. Not us, we built a Great Coalition from Boston Scientific to working with your talented people in this and we have a good piece of legislation on it and were trying to communicate to implement it and were leave in a nomansland and i dont like to go out and hammering on you that we havent heard from you yet but this is important stuff. And these are things i encourage my colleagues to ask in, that is in the step Care Management. The things from dr. Benishek are in the step management and if we make it best practices and s. O. P. It would be there. I encourage you in many cases, if you are doing something right, let us know and talk about it, communicate with us, see us as partners in helping our veterans so the frustration you hear both here and out in our districts is reduced. So well look forward to the followup and i yield back. Thank you, mr. Walz. Dr. Raul, tennessee. Thank you mr. Chairman and just a couple of things. One on Data Collection and certainly when you draw or produce inadequate data, you draw inadequate results an the results may not be accurate at all. And it is extremely important in healthcare to get the data right because were going to draw con cluss based on this many patients did this and did that and the outcome, ive been involved in those clinical studies for years. And when you put bs in, you get bs out. And that is sort of what it looks like what is happening here. And to be crude, it looks like that is what youve done. And mr. Williamson pointed out, you have half of the vha templates incomplete or inaccurate, you draw bad conclusions from that. And you cant help but do it. So until you get the data right, you will never know. And dr. Clancy, you are right, what works for one patient may not work for another and the Ranking Member pointed out there are different alternatives and what works and dr. Murfy who im sure you know continually complains about when he is at d. O. D. And has a pashl table and then separated from the military and they go to the v. A. , there is a different formula so they stop all of what hes taken forever to get the patient stable on and now on something else. That is something that needs to be addressed. He was very adamant that he sees it a lot since he is still in clint cal practice. And i too with dr. Benishek, i think the outburst you heard was frustration with a veteran that tried to get in and couldnt. And mr. Orourke has ever right to be frustrated when he has people lined up outside of his office talking about not being able to get into the v. A. And let me share why that is frustrating to me. Ive been here six years and change on this committee. And weve increased the budget 64 . It is not money. It is management. It is not the amount of money we are spending on our veterans. There is plenty of money to spend. I dont understand why the system isnt functioning better. Any comments on that, because mr. Pointed out in your testimony poor oversight, why is that . No accountability. What happens to someone when we find out theyre just not following. Apparently nothing. So i know theres and then outcomes. You mentioned all of those things. Mr. Williams . So your question is directed at oversight . Yes, sir. You know, theres a lot of reasons why that doesnt happen and i think a lot of times v. A. Does not have the data to real real accurate and complete data to do that kind of thing. I dont think theres any willful motive on v. A. s part. I think its just audit times, especially at the local level. There is just not that accountability that a supervisor is holding his or her employee accountable for doing their job correctly. But thats that seems basic to doing your job to me. I mean, to hold someone accountable for their job, thats not rocket science. Youre not doing your job. So what happens when you dont do your job . Do you lose your job . What happens . Im not sure im the right one to ask that, but you know in my idealistic world i would think you would. Were held accountable for the quality of the work we do and when we dont do it well we get feedback. We get expectations and feedback and thats business 101. So dr. Rowe, if i might i want to say to you and your colleagues we share your frustration. And i want to salute my colleague dr. Cuddler who is working with others to try, yes, someone people who dont do their jobs should be held accountable if, in fact, we have given them the resources and capacity to do that job. You cant hold somebody accountable if there are no appointments and no ability to see a patient. But mr. Ororke pointed out there are 20 something people, Jobs Available right now. We claim to have a job problem. There are 24 people that need a job in el paso, texas, and theres money there to find it. So why arent those positions filled . We have tried a lot of varieties of ways to recruit people. Mr. Ororke came in with a group of partners from the community and i think im very much looking forward and he has my full commitment to looking that the proposal to see how v. A. Is not making it hard for those veterans to leave that practitioners, with the veterans choice card, nonv. A. Care, we find that sometimes. Its so hard with the rules they have to get out it takes forever. And one last thing and then my time expires. How long does it take to change a phone number . Why does it take six months i know when i get frustrated, punch 2 for this, 3 for that, how hard is it to do when someone is contemplating suicide to have a phone changed to where they go straight to a person. We want to make sure we dont overstress the people who are taking the calls, one of whom recently took their own life. As you can imagine. That is a very, very stressful job. So thats the reason were just testing it first in about 20 different facility this is summer and well then roll it out full steam this fall. That may be stressful. Im very sorry for that family. But its very stressful on the other end. I understand that completely and we want to make sure that when you hit that one number or whatever the number will be that, in fact, it connects you to directly to a counselor. Because the only thing worse than not having it is doing it then. And i have to say that the issue of transitioning Service Members over to v. A. , they continue on the drugs that they were getting in the service. Weve gone over this with dr. Woodson i will ask dr. Murphy today again when i see him on the house floor. Hes around different impression. And i would be happy to follow up with him as well because if weve missed something in our surveys of veterans we want to know about that and fix it. Miss rice, new york . Thank you, mr. Chairman. I hate to say that maybe the stress for the poor operators comes from the fact that they know theyre not going to have the support from the v. A. In getting the callers the help they need. Id like to take a minute to recognize the work being done in my home state in haveisn that covers the bronx and manhattan. They specifically reject the are prescribe first diagnose later treatment philosophy that i think is all too often adopted by the v. A. They have taken, again, what shouldnt be a revolution their approach to Pain Management. They actually believe that the first thing you do is diagnose the patient before developing a path of treatment. And instead of prescribing opiates as the default for treatment for veterans suffering for pain and i understand for doctors when a patient presents with real pain, you want to take away the pain. I get a test Doctors First mode of reaction. But this facility is using alternative approaches such as a acupuncture and exercises to relieve pain and what weve seen is veterans who undergo these treatments experience relief from pain without the harmful effects of addictive narcotics. The bronx v. A. s outstanding approach to pain treatment should become the norm at all v. A. Facilities nationwide. My question is to you, dr. Clancey, what is the v. A. s aversion to alternative forms of treatment like meditation, acupuncture and exercise . First of all, let me say, i completely share your enthusiasm for what i believe its visn 3 is doing. Ive spoken to those folks. Its wonderful. And we have many thousands of veterans actually using alternative forms of therapy, so there is no aversion whatsoever. For veterans who are already getting opiates, like other american, and some of whom come to us from active duty on those same medications, the path forward is going to be different. Its not starting from day one. So i love what theyre doing in new york and i have spoke within many veterans and have actually begun to think about how we might use their stories to help those who are struggling to get off opioids and try alternatives. Many of the veterans who take opioids would like not to. But theyd like to kind of wake up and it would all be okay. The journey there is not so easy. So we actually have but we have a system here that we know works. And i think it was one of my colleagues who told this story about noah. And clearly he was just prescribed drugs. He was not given any followup, any alternative, any therapy, anything like that. The doctor whos in charge of visn 3, she stated she made a statement that i thought was very accurate. She said that to be on opiates is to be trapped in a cycle or poor function and poor pain control and thats what we need to get away from. And im just imploring you, its not racket science. They get it right there. Just export it throughout the rest of the country. One other thing that i wanted to talk about is a bill that is that i happen to be a proud cosponsor of thats put forth by our colleague ron kind from wisconsin. Its hr1628, veterans Pain Management improvement act which would establishment a Pain Management board within each visn to better handle treatment plans for patients with complex clinical pain. They would incorporate doctors, patient, family members into the Decision Making process for a veterans course of treatment. Has the vha taken the ideas for this bill under advisement . Yes. Representative kind asked us for our comments and i told him he had my personal full throated support which may be different than the Department Support but i cant think of any reason we would not support that fully. It was really inspired by that in updating our clinical practice guideline i wanted to make sure that we had input from veterans and families in doing just that. And i told him that. I think thats because as heartbreaking as some of the experiences of the veterans are, are the experiences of families who raised their hands and said im worried about my son, daughter, spouse whatever. Because its a family issue, not just a Service Person issue. Its a family issue. And i dont think we want to be a nation that says to our brave men and women who fight for us and come back so damaged and so injured that we are going to do our best to keep you in a catatonic state for the rest of your life as a Pain Management therapy. That just cannot be where we come down on this. So im bigging you to do everything that you can to look what the theyre doing in visn 3 and export it throughout the rest of the country. Its not rocket science. Thank you very much, mr. Chairman. I think if i was going to sum up this hearing with Veterans Health administration it would simply be that drugs are a short cut. Theyre a short cut to doing the right thing. They are a shortcut to doing the therapies that are really required to treat our veterans, both mentally and physically in terms of Pain Management and in terms of those suffering from depressive disorders and i think that thats disconcerting. And its unfair and hurtful to the men and women who have made tremendous sacrifices for this country in uniform. And one question i have that is how many physiologists or rehabilitation physicians does the Veterans Administration have . Dr. Clancy . I would have to take that for the record, mr. Chairman. Ill get back to you. Ive got the number of about 40. So there is lies part of the problem. Those are the people central when it comes to Pain Management yet were shortchanging that because, again, the easy thing to do is to drug someone. Drug them not to feel pain. Drug them to get them up in the morning. Drug them so they can go to sleep at night and i think when we look at the ssds rates of our veterans, thats reflective of what the Veterans Administration is doing in terms of having drugreliant therapies. Again, as a short cut for doing the right thing. Dr. Muffussi, are you a veteran yourself . I am not. I am neuroscientist by training and prior to iva worked for the pentagon on Behavior Health issues with army Suicide Prevention task force and other programs. I want to thank you for your work on behalf of the men and women who serve this country. What is your view about do that you believe, in fact, the overprescription of drugs is a shortcut . I think this is a really complex question to ask because if you look at the history of clinician education, medications have always kind of been at the forefront. Particularly with Pain Management. As a neuroscientist i can tell you the research is young and we dont know a lot about how it manifests. We dont have a lot of great treatment options. However, having said that, theres a lot of research coming out right now that really support this is idea of integrated management of pain using alternative and complementary medicines. Theres there are some spinal cord stimulation is a new technology thats out there andiva has a member veteran who was addicted to opioids, was a chronic pain sufferer and was able to get off of those drugs and through spinal cord stimulation and through alternative practices lives a much better life now as a result. But these are all very new technologies. Doctors know about them. Theyre not using them. And so clinician education is so, so critical to redefining how clinicians will get Pain Management. Well, i think you would agree, though, that it shouldnt be drugs should not be the first course of action, they should be the last course of action. Absolutely. I think drugs are drugs are one option of many and they might be necessary but they shouldnt be the end all be all. They need to be a part of a comprehensive plan. Mr. Williamson, how would you view the in terms of the principal modalities of treatment, whether for psychotherapy or for Pain Management, from what were seeing here in terms of testimony, it seems to be kind of the first and preferred method of treatment tends to be drug therapy. Well, im not a clinician and im not qualified to answer that. But we are going to be looking at the v. A. Operations relative to open void the Program Later this year. So ill be much more educated after that. Well, thats not comforting. I wish you were prepared here to know. Mr. Kudler, dr. Kudler, what do you think . Im really glad you asked that question. Uhoh. Well, lets not run the clock here. The bottom line is this whether its pain or depression it takes an integrated approach just as dr. Maffucci was saying. Different patients need to start in different places. There are patients who say i cant talk about this, i wont talk about this and the medication will make that possible in a depressive case. In a pain case, there are people who absolutely need not to go where they mean to go, into opiates or come off them but they believe this is all that would ever work for them. So we need to start where the veteran is and use a mixture. With my patients ive said, look, i have a lot of different tool, talk therapies and medication, this is the good and bad about each of them, what makes sense to you and, by the way, we can do both and in most cases we end up doing both but often in a stepped way. Dr. Clancy, in an oig report from 2013 it was recommended that v. A. Ensure that facilities take action to improve postdischarge followup for Mental Health patients, particularly those who are identified as high risk for suicide. What is being done to ensure this process being followed . A few years ago, v. A. Put out as a performance measure that veterans must be seen in person or at least by phone in the first seven days after leaving a psychiatric hospital. And this is based on statistics that show this is the most vulnerable time the first two weeks, the most vulnerable time for a suicide attempt, especially after treatment for depression or admission for suicide activity. We have been monitoring this, we are not perfect in this but i cant give you the number now, i can provide it later. We are at a point where all across the nation were tracking this, we have automatic alerts, we have team this is that do this work with people and weve taken it miles further. I wish i could give you the number right now. You know what is amazing, from what were hearing on the ground and in this committee, its a world apart and if for what were hearing in this committee were true we wouldnt be here today having this discussion. Well, mr. Chairman, if i might, were not sayingzbcf everything is fine. And i acknowledged that at the outset. What i want to tell you that we are committed to getting it right. This is tough work and we have a lot to improve on and we very much welcome your support and help. Very hard to get it right if youre not acknowledging the depth of the problem. Ranking member custer . Thank you very much. Thank you, mr. Chairman, and thank you to our committee, to our panel for coming forward and the all the comments from the committee. I just want to follow up on how where we go from here in terms of sharing best practices. Weve now heard dr. Maffucci, i appreciate your commentary and expertise in this area and to the team from the v. A. Weve heard about visn 1, ive talked about some examples in White River Junction. How do these best practices get shared and the research thats under way, how do we move forward with this to make sure more veterans and their families will be served by this. And in particular the clinician education. Because i think weve got to change some of the parameters and some of the sort of go to answers that some of the clinicians have. Where do we go from hear what this and how can this committee best stay on top . Fc of that an continue to work with the v. A. To make sure that we are serve the veterans all across the country. This involves a Case Management intensive approach and youre right. The worst Case Scenario to cancel somebodys medication without followup. We know thats why people are turning to heroin in the streets some how do we get this right and across the board in the v. A. And what s the followup . What i might suggest is that you invite us back for a briefing and we would give you the followup. You pick the frequency, a couple month, three months. And i wanted to i didnt get a chance to say before to congressm congressm congressm congressm congressm congressm congressman oroark that we are monitoring that and when someone changes its easy to say no to open noids. Thats not unusual and its in definition of success here. I wanted to be very clear on this point. Some of these challenges are areas where u. S. Medicine is struggling in general. Chronic pain in particular and for Mental Health weve had to blaze trails. Theres no clearcut blood test that one cant do like blood sugar, blood pressure, whatever, to double check on the diagnosis or assessment. It depends on the use of the standardized questions. You should hold us accountable and i look forward to where weve been and where were going. In no way do i not want to say that we have problems to solve, we do. We own them and are looking forward to solving them. Where you can help is helping to work with us on reducing stigma. I mean, this remains a huge, huge problem. Also i think sending a sense that youre supporting the efforting to get better claire for veterans. One of our challenges is that a long of young people are not choosing to go goo into these fields and thats the ultimate recruitment problem. If theyre not going we have terrific incentives thanks to the clayhunt act in terms of Debt Reduction thanks to the veterans choice act and so forth and those are great tools but someone has to actually make the decision to go down that path. Thank you very much. Thank you. Dr. Clancy, i want to stress again the need for you to turn over documents requested by congress and your failure to do so makes our job very difficult. Mr. Oroark from texas. Dr. Clancy, thank you for addressing the el paso issue and the larger issue within the v. A. To ensure youre monitor iing those veterans coming off of opiates but the feedback stands because im hearing it directly from veterans that thats apparently not happening in el paso. And i think we must conclude that for every veteran kbho who takes the time to come down to a town hall meeting despite what theyre going through to tell their congressman theyre having this problem in front of 200 other veterans and is n admitt they are receiving opiates and now are doing without that there are many others that that person represents whos given up and says why should i bother . So we have a problem in el paso, perhaps nationally in terms of ramping people down or