Carolyn Clancy, M.D.
STATEMENT OF
DR. CAROLYN CLANCY
INTERIM UNDER SECRETARY FOR HEALTH
VETERANS HEALTH ADMINISTRATION
DEPARTMENT OF VETERANS AFFAIRS
BEFORE THE
subcommittee on oversight and investigations
COMMITTEE ON VETERANS’ AFFAIRS
United States HOUSE OF REPRESENTATIVES
June 10, 2015
Good morning, Chairman Coffman, Ranking Member Kuster, and Members of the Committee. Thank you for the opportunity to discuss the provision of mental health care to Veterans, particularly those who are at risk for suicide. I am accompanied today by Dr. Harold Kudler, Acting Chief Consultant for Mental Health Services and Mr. Michael Valentino, Chief Consultant of Pharmacy Benefits Management Services. My written statement will discuss VA’s many initiatives enhancing the appropriate use of prescription medications as well as VA programs caring for individuals who experience mental and substance use disorders, including programs for suicide prevention.
Opioid Safety Initiative
Chronic pain, which is a major health problem for Servicemembers and Veterans, is also a national public health problem as outlined in the 2011 study by the Institute of Medicine (IOM). At least 100 million Americans suffer from some form of chronic pain. The IOM study describes in detail many concerns about pain management, including system-wide deficits in the training of our Nation’s health care professionals in pain management and the problems caused by a fragmented health care system. The over-use and misuse of opioids for pain management in the United States are a consequence of a health care system that continues to struggle with these challenges. About 30% of the U.S. adult population experiences chronic pain, a large number to manage. The problem of chronic pain in the VA is even more daunting with 50% to 60% of Veteran patients experiencing chronic pain due to battle field and other service related injuries. It is important to note that nationally, most patient deaths from overdose are unintended. Many Veterans have also incurred head injuries, collectively referred to as traumatic brain injuries (TBI), which can compound psychological injuries such as post-traumatic stress disorder resulting from their experiences. The combination of pain, a head injury and mental health disorder can further degrade quality of life for Veterans and their families, increasing the risk for overdose, substance abuse, and suicide.
The VA health care system has identified and broadly responded to the many challenges of pain management through policies supporting clinical monitoring, education and training of health professionals and teams, and expansion of clinical resources and programs. The Opioid Safety Initiative (OSI) was implemented system-wide in August 2013 and is producing the desired results. The goal of the OSI is to make the totality of opioid use visible at all levels in the organization. The OSI includes key clinical indicators such as the number of unique pharmacy patients dispensed an opioid, unique patients on long-term opioids who receive a urine drug screen, the number of patients receiving an opioid and a benzodiazepine (which puts them at a higher risk of adverse events) and the average morphine equivalent daily dose (MEDD) of opioids. Results of key clinical metrics measured by the OSI from Quarter 4 Fiscal Year 2012 (beginning in July 2012) to Quarter 2 Fiscal Year (FY) 2015 (ending in March 2015) are:
o 109,862 fewer patients receiving opioids
o 33,871 fewer patients receiving opioids and benzodiazepines together
o 74,995 more patients on opioids that have had a urine drug screen to help guide treatment decisions
o 91,760 fewer patients on long-term opioid therapy
o The overall dosage of opioids is decreasing in the VA system as 12,278 fewer patients are receiving greater than or equal to 100 Morphine Equivalent Daily Dosing.
o The desired results of the Opioid Safety Initiative have been achieved during a time that VA has seen an overall growth of 90,488 patients that have utilized VA outpatient pharmacy services.
Special Medication Concerns
Psychotropic Drug Safety Initiative
In an effort to ensure our Veterans receive safe, effective and evidence-based psychopharmacologic treatments, the VHA launched the Psychotropic Drug Safety Initiative (PDSI) in December of 2013. The PDSI is a VHA nation-wide quality improvement initiative coordinated through the Office of Mental Health Operations (OMHO) in collaboration with Mental Health Services (MHS) and Pharmacy Benefits Management (PBM). Every VAMC in the country has been required to participate through local or VISN-wide quality improvement initiatives. The PDSI aims to address possible overprescribing, possible problems in clinical management, misalignment between prescribing and diagnosis, and meeting specific mental health needs through pharmacotherapy. The key aspects of this program include developing measures and sharing data with VISNs and facilities, providing feedback and support for local quality improvement action planning, supporting a collaborative community of practice, and disseminating information about psychotropic prescribing.
The PDSI program utilizes a dashboard that contains indicators of prescribing practices intended to facilitate quality improvement by helping providers prioritize patients to review. The PDSI program also conducts twice monthly QI collaborative conference calls. Even though this program has only been operational for just over a year, it has already demonstrated a positive impact. As of the end of quarter 1 of FY2015, we have seen significant improvement in the national score of 14 of the 20 PDSI measures. For example, the proportion of Veterans with alcohol use disorder who received pharmacotherapy treatment rose over 1% nationally, which means 5,902 additional Veterans received these evidence-based treatments. Similarly, the proportion of Veterans with opiate use disorder who received opiate agonist therapy increased nearly 2% nationally, with an additional 2,420 Veterans receiving these evidence-based treatments. We have also noted a 2% decrease nationally in the proportion of Veterans with PTSD receiving benzodiazepines and a 1% decrease in the proportion of Veterans with PTSD and no psychosis diagnosis who received an antipsychotic medication.
Academic Detailing Initiative
On March 27th 2015, I mandated national implementation of an Academic Detailing Initiative in every network by June 30th, 2015. Based on the results of a 3-year pilot, I believe Academic Detailing holds the promise of continued progress personalizing Veterans’ pain management and assure medication safety in our most vulnerable Veterans with Mental Health concerns. This program was designed to allow specially trained clinical pharmacists to assess individual providers’ prescribing practices and meet with them one-on-one over a period of time to identify any treatment gaps. The goal of these meetings is to aligning individual prescribing practices with published medical evidence where gaps exist. Clinical pharmacists from 16 of the 21 networks are engaged in training for academic detailing interventions; 130 clinical pharmacists have already completed the required training for delivering the behavior change interventions with prescribers. Thus far, 1534 interventions of academic detailers have been recorded. The topics covered in these interventions include pain and opioid use in 872 interventions, 389 for Opioid Overdose Education and Naloxone Distribution and 174 for benzodiazepine safety.
Overdose Education and Naloxone Distribution (OEND)
VHA has also undertaken a national initiative to make overdose education and naloxone rescue kits available to patients at risk of accidental or intentional overdose. Naloxone can reverse an opioid overdose, preventing overdose death and morbidity when administered in a timely manner. Distribution of overdose rescue training and naloxone kits is a novel intervention within health care settings, and it is being rapidly adopted by VA. To date, 822 VHA providers have begun prescribing these kits to at risk patients, with over 4250 patients receiving training and kits. Already, Veterans have reported reversing 70 opioid overdoses with the naloxone VHA prescribed, representing potential lives saved from these efforts.
VHA has developed a predictive model and clinical decision-support tool to identify patients with opioid prescriptions at risk of suicide-related events and overdose. This tool is being pilot tested and optimized with pain and mental health specialists.
VHA has continued efforts to ensure that effective substance use disorder treatments are available for patients with substance use disorders, knowing that they have an elevated risk for suicide and overdose. Greater engagement in VHA substance use disorder programs is associated with lower suicide attempt risk and reduced criminal behavior in Veterans initiating substance use disorder treatment. VHA continues to increase availability of specialty substance use treatment, increasing the number of patients treated per year with specialty treatment services and with opioid agonist treatment for opioid use disorders.
National Take-Back Initiative
In September 2014, the Drug Enforcement Administration (DEA) published a final rule for the Secure and Responsible Drug Disposal Act of 2010 in the Federal Register, effective October 9, 2014. This Rule provides three voluntary methods for ultimate users (e.g. Veterans) to dispose of their unwanted/unneeded medications in a secure and responsible manner: 1- Mail Back Packages, 2- On-site Collection Receptacles, and 3- Take Back Events.
VA has been aggressively planning and implementing drug disposal options for Veterans. A Directive, which is currently in concurrence, will require VA medical centers to implement at least one practical, accessible, and secure disposal method, when appropriate and in compliance with DEA regulations. In April 2015, Mail Back Envelopes were provided to all VA facilities for distribution to Veterans. Guidance on envelope distribution to maximize Veteran engagement and use was also provided and as of May 31st, 2015, 369 envelopes, which contained approximately 160 pounds of unwanted/unneeded medication, have been returned to a vendor for environmentally responsible destruction.
VA is also piloting the use of on-site collection receptacles in 6 VA medical centers. The pilot involves pharmacy and Security & Law Enforcement staff with different sites of care including ambulatory care, community living centers and residential treatment programs. Data will be gathered on Veteran usage, feedback, safety, costs, and resource utilization to evaluate decisions going forward. Thus far, both Veterans and staff report a high level of satisfaction with this service and approximately 800 pounds of unwanted/unneeded medication have been collected and destroyed. Removal of this medication from Veterans’ homes reduces the risk of diversion as well as intentional and unintentional overdoses and poisonings.
Mental Health Overview
Since September 11, 2001, more than two million Servicemembers have deployed to Iraq or Afghanistan. Long deployments and intense combat conditions require comprehensive support for the emotional and mental health of Veterans and their families. Accordingly, VA continues to develop and expand its mental health and substance use disorder programs as an integrated system of care. The number of Veterans receiving specialized mental health treatment from VA has risen each year, from 927,052 in Fiscal Year (FY) 2006 to more than 1.5 million in FY 2014. We anticipate that VA's requirements for providing mental health care will continue to grow for a decade or more after current operational missions have come to an end. VA believes this increase is partly attributable to proactive screening to identify Veterans who may have symptoms of depression, post-traumatic stress disorder (PTSD), substance use disorder, or those who have experienced military sexual trauma. In addition, VA has partnered with the Department of Defense (DoD) to develop the VA/DoD Integrated Mental Health Strategy to advance a coordinated public health model to improve access, quality, effectiveness, and efficiency of mental health services for Servicemembers, National Guard and Reserve, Veterans, and their families.
VA has many entry points for VHA mental health care. These entry points include medical centers, Community Based Outpatient Clinics (CBOCs), Vet Centers providing readjustment counseling, a Veterans Crisis Line, VA staff on college and university campuses, and other outreach efforts. To serve the growing number of Veterans seeking mental health care, VA has deployed significant resources and increases in staff toward mental health services.
VA has expanded access to mental health services with longer clinic hours, telemental heath capability to deliver services, and standards that mandate immediate access to mental health services to Veterans in crisis. In an effort to increase access to mental health care and reduce any stigma associated with seeking such care, VA has integrated mental health into primary care settings. From the beginning of FY 2008 through March 2015, VA has provided more than 4.7 million Primary Care-Mental Health Integration (PC-MHI) clinic visits to more than 1,137,000 unique patients. This improves access by bringing care closer to where the Veteran can most easily receive these services, and improves quality of care by increasing the coordination of all aspects of care, both physical and mental. In addition, a second round of VA Community Mental Health Summits has recently been completed at virtually all major VA facilities across the nation and analysis of feedback from VA and Community participants is underway. Based on 2013 Summit recommendations, Community Mental Health Points of Contact have been identified at every VA Medical Center. The Community MH POC provides ready access to information about VA eligibility and available clinical services, ensures warm handoffs at critical points of transition between systems of care, and provides ongoing liaison between VA and Community Partners. At each of the 2014 Summits, featured presentations included best practices in support of military and Veteran families in populating the National Resource Directory to enhance referrals to VA and community resources across America for use by any Servicemembers, Veterans, family members, referring clinicians or other stakeholders.
VA has made deployment of evidence-based therapies a critical element of its approach to mental health care and offers a continuum of recovery-oriented, patient-centered services across outpatient, residential, and inpatient settings. State-of-the-art treatment, including both psychotherapies and biomedical treatments, are available for the full range of mental health problems, including Post- Traumatic Stress Disorder (PTSD), substance use disorders, and suicidality. While VA is primarily focused on evidence-based treatments, we are also assessing complementary and alternative treatment methodologies that need further research, such as meditation and acupuncture in the care of PTSD. For example, a recently published clinical trial suggests that mindfulness techniques were as effective in treating depression as antidepressants. VA has trained over 6,100 VA mental health professionals to provide two of the most effective evidence-based psychotherapies for PTSD, Cognitive Processing Therapy and Prolonged Exposure Therapy, as indicated in the VA/DoD Clinical Practice Guideline for PTSD[1]. VA operates the National Center for PTSD, which guides a national PTSD mentoring program, working with every specialty PTSD program across the VA health care system. The Center has begun a PTSD consultation program for any VA practitioners (including primary care practitioners and Homeless Program coordinators) who request consultation regarding a Veteran in treatment with PTSD. So far, the consultation program has provided over 2,600 consultations and triaged an additional 165 requests from the Suicide Risk Management Consultation Program. Starting in January 2015, the PTSD Consultation program has expanded so that providers outside of VA can now consult with the program as well as VA providers.
Specialized mental health centers of excellence (CoE) are another essential component of VA’s response to meeting the mental health needs of Veterans. These centers, including 10 Mental Illness Research, Education and Clinical Centers (MIRECC), the National Center for PTSD and four additional centers strive to improve the health and well-being of Veterans through world-class, cutting-edge science, education and clinical care. The centers are designed to be incubators for new investigators, new clinicians, new treatments, new ways of educating staff and patients, and new ways of delivering care.
We know that there have been issues with Veteran access to care. We take those concerns seriously and continue to work to address them. In addition, receiving direct feedback from Veterans concerning their care is vitally important. During Quarter 4 of FY 2013, as part of VHA’s effort to seek direct input from Veterans in understanding their perceptions regarding access to care, we conducted a survey of over 40,000 Veterans who were receiving mental health care. The replication of that survey for FY2015 is currently underway and approximately 50,000 Veterans who have received mental health services will be surveyed by the end of July 2015 about their perceptions of mental health services. These results, and other outreach to Veterans, aid us as we strive to improve the timeliness of appointments; reminders for appointments; accessibility, engagement, and responsiveness of clinicians; availability and agreement with clinician on desired treatment frequency; helpfulness of mental health treatment; and treatment with respect and dignity.
Programs and Resources for Suicide Prevention
Overall, Veterans are at higher risk for suicide than the general U.S. population, notably Veterans with PTSD, pain, sleep disorders, depression, and substance use disorders. VA recognizes that even one Veteran suicide is too many. We are committed to ensuring the safety of our Veterans, especially when they are in crisis. Our suicide prevention program is based on enhancing Veterans’ access to high-quality mental health care and programs specifically designed to help prevent Veteran suicide.
In 2011, the age-adjusted rate of suicide in the U.S. general population was 12.32 per 100,000 persons per year. At just over 12 for every 100,000 U.S. residents, the 2011 rate of suicide has increased by approximately 15 percent since 2001. Rates of suicide in the United States are higher among males, middle-aged adults, residents in rural areas, and those with mental health conditions.
The most recent available data show that suicide rates are generally lower among Veterans who use VHA services than among Veterans who do not use VHA services. In 2011, the rate of suicide among those who use VHA services was 35.5 per 100,000 persons per year; a decrease of approximately 6 percent since 2001. Rates of suicide among those who use VHA services have remained relatively stable; ranging from 35.5 to 37.5 per 100,000 persons per year over the past 4 years. Despite evidence of increased risk among middle-aged adults (35-64 years) in the U.S. general population, rates of suicide among middle-aged adults who use VHA services have decreased by more than 16 percent between the years 1999-2010. Decreases in suicide rates and improvements in outcomes were also observed for some other high-risk groups. Between 2001 and 2010, rates of suicide decreased by more than 28 percent among VHA users with a mental health or substance abuse diagnosis, and the proportion of VHA users who die from suicide within 12 months of a survived suicide attempt has decreased by approximately 45 percent during the same time period. Available data suggest suicide risk is not evenly distributed across all Veteran groups. More than 70% of all Veteran suicides occur among adults aged 50 years and older. Recent analyses of VA data (2000-2010) also identified significant increases in rates of suicide among male Veterans between the ages of 18 and 29 years and there is evidence of increased risk for suicide among female Veterans of all ages when compared to females in the U.S. general population.
The Veterans Crisis Line/Military Crisis Line
In partnership with the Substance Abuse and Mental Health Services Administration's National Suicide Prevention Lifeline, the Veterans Crisis Line/Military Crisis Line (VCL/MCL) connects Veterans and Servicemembers in crisis and their families and friends with qualified, caring VA responders through a confidential toll-free hotline (1-800-273-TALK (8255), then press 1) that offers 24/7 emergency assistance. August 2014 marked seven years since the establishment of the initial program, which was later rebranded to show its direct support for Servicemembers. It has expanded to include a chat service and texting option. As of the end of March 2015, the VCL/MCL has rescued 48,000 actively suicidal Veterans. As of March 2015, VCL/MCL has received over 1,746,000 calls, over 217,000 chat connections, and over 35,000 texts; it has also made over 282,000 referrals to Suicide Prevention Coordinators. Based on the 2012 Presidential Executive Order, we expanded the capacity of the Veterans Crisis Line by 50 percent.
Suicide Prevention Coordinators
VA has a network of over 300 Suicide Prevention Coordinators (SPC) located at every VA medical center and the largest CBOCs throughout the country. Overall, SPCs facilitate implementation of suicide prevention strategies within their respective medical centers and clinics to help ensure that all appropriate measures are being taken to prevent suicide in the Veteran patient population, particularly Veterans identified as being at high risk for suicidal behavior, and the SPCs engage in outreach to other Veterans, family members, and community partners.
SPCs are responsible for implementing VA’s Operation S.A.V.E (Signs of suicidal thinking, Ask the questions, Verify the experience with the Veteran, and Expedite or Escort to Help). This is a one-to-two hour in-person training program provided by VA SPCs to Veterans and those who serve Veterans to help prevent suicide. Suicide prevention training is provided for every new VHA employee during Employee Orientation. Our goal is to increase mental health awareness wherever Veterans and their family members are present and to continuously enhance and expand our response to their needs.
SPCs participate in outreach activities, meetings with state and local suicide prevention groups with Active Duty/National Guard and Reserve units as well as college campuses. Each SPC is required to complete five or more outreach activities in his or her local community each month. To ensure that high-risk Veterans are being monitored appropriately, SPCs manage a Category I Patient Record Flag (PRF) with a corresponding High-Risk List. The primary purpose of the High Risk for Suicide PRF is to communicate, consistent with appropriate privacy protections, to VA staff that a Veteran is at high risk for suicide, and the presence of a flag should be considered when making treatment decisions. SPCs ensure that all Veterans identified as high risk for suicide have completed a safety plan that is documented in their medical record, and that the Veteran is provided a copy of his or her safety plan.
The Joint Suicide Data Repository
In 2010, DoD and VA launched a Joint Suicide Data Repository (SDR) as a shared resource for improving our understanding of patterns and characteristics of suicide among Veterans and Servicemembers. The combined DoD and VA search of data available in the National Death Index represents the single largest mortality search of a population with a history of military service on record. The DoD/VA Joint SDR is overseen by the Defense Suicide Prevention Office and VA’s Suicide Prevention Program.
On February 1, 2013, VA released a report on Veteran suicides including data from the SDR, a result of the most comprehensive review of Veteran suicide rates ever undertaken by VA. With assistance from state partners providing real-time data for SDR, VA is now better able to assess the effectiveness of its suicide prevention programs and identify specific populations that need targeted interventions. This new information will assist VA in identifying where at-risk Veterans may be located and improving the Department’s ability to target specific suicide interventions and outreach activities in order to reach Veterans early and proactively. These data will also help VA continue to examine the effectiveness of suicide prevention programs being implemented in specific geographic locations (e.g., rural areas), as well as care settings, such as primary care, in order to replicate effective programs in other areas. VA continues to receive state data that is being included in the SDR. VA plans to update the suicide data report later this year.
VA’s National Efforts
Suicide prevention efforts must extend to reach Veterans who may not seek assistance. Therefore, VA has focused on increased targeted outreach efforts throughout the country to Veterans and their family members with significant emphasis on safety. We encourage Veterans and their families to learn more about mental illness and to take precautions particularly during times of stress.
VA has sponsored public service announcements, rebranded and optimized the VCL/MCL Web site for mobile access and viewing, and developed social and traditional media advertisements designed to inform Veterans and their families of VA’s VCL/MCL resources. During National Suicide Prevention Month in September 2014, VA launched its new outreach campaign theme for this year, “The Power of 1,” which emphasizes that just one person, one conversation, or one small act can make a big difference to a Veteran or Servicemember in crisis.
Furthermore, VA is engaged in ongoing research to determine the most effective mental health treatments and suicide prevention strategies. VA has also established the Mental Health Innovations Integrated Project Team that is working to implement early intervention strategies for specific high-risk groups. Through early intervention, VA hopes to reduce the risk of suicide for Veterans in these high-risk groups.
Another national suicide prevention initiative is VA’s Behavioral Health Autopsy Program (BHAP). BHAP is designed to enhance suicide prevention efforts by systematically collecting information for all deaths by suicide reported to VHA clinicians and Suicide Prevention Coordinators. BHAP is a multiphase quality improvement initiative that consists of standardized chart reviews for all Veterans’ suicides known to VHA staff and interviews with bereaved family members. Medical chart reviews of suicide decedents offer important clinical information concerning Veterans’ VHA service utilization.
In addition, VA established an online Community Provider Toolkit for individuals outside of VA who provide care to Veterans. This provides an important resource in the wake of the Veterans Access, Choice, and Accountability Act of 2014. This Web site features key tools to support the mental health services provided to Veterans including information on connecting with VA, understanding military culture and experience, and working with patients with a variety of mental health conditions.
Readjustment Counseling Service
VA’s Readjustment Counseling Service (RCS) provides a wide range of readjustment counseling services to eligible Veterans and active duty Servicemembers who have served in combat zones and their families. RCS also provides comprehensive readjustment counseling for eligible Veterans and Servicemembers who experienced military sexual trauma, as well as offering bereavement counseling to immediate family members of Servicemembers who died while on active duty. These services are provided in a safe and confidential environment through a national network of 300 community-based Vet Centers located in all 50 states (as well as the District of Columbia, American Samoa, Guam, and Puerto Rico), Mobile Vet Centers, and the Vet Center Combat Call Center (877-WAR-VETS or 877-927-8387). In FY 2013, Vet Centers provided over 1.5 million visits to Veterans, active duty Servicemembers, and their families. The Vet Center program has provided services to over 30 percent of Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn Veterans who have left active duty. As the President announced in August 2014, the First Lady and Second Lady’s Joining Forces initiative is promoting awareness of Vet Centers for combat Veterans, Servicemembers, and their families.
Research
VHA is engaged in multiple research projects related to mental health, suicide and violence, as well as optimizing pharmacological and non-pharmacological interventions for pain and psychiatric conditions. Several current studies are addressing opioid use, including:
· An ongoing study, titled “Impact of Interventions to Reduce Violence and Substance Abuse among VA Patients” that focuses on the use of new intervention approaches targeting the use of violence prevention skills and means of sustaining substance use remission.
· A recently funded study focused on Justice-involved Veterans (i.e. those detained by or under the supervision of the criminal justice system) that aims to improve utilization of VHA mental health/ substance abuse disorder (SUD) care.
· An ongoing study seeking to provide guidance on indications for opioid reassessment in primary care.
· An ongoing study examining a program called “Comprehensive Opioid Management in Patient Aligned Care Teams” that uses a web-enabled electronic, interactive voice response telephone monitoring and care management system to facilitate patient engagement, conduct regular opioid monitoring and provide relevant education.
· An ongoing study examining opioid prescribing in VHA before and after the Opioid Safety Initiative.
In addition, the Pain Workgroup of the SUD, Quality Enhancement Research Initiative (QUERI) is working to increase utilization of non-pharmacological, evidence-based pain management in specialty SUD treatment settings, and to improve the understanding and measurement of opioid misuse in SUD specialty care.
Closing Statement
Mr. Chairman, VA is committed to providing timely, high quality care that our Veterans have earned and deserve, and we continue to take every available action and create new opportunities to improve suicide prevention services.