VIETNAM VETERANS OF AMERICA
Mr. Chairman, Ranking Member Miller, distinguished members of this Subcommittee, and guests, Vietnam Veterans of America (VVA) thanks you for the opportunity to present our views on substance abuse and co-morbid disorders. Foremost, Vietnam Veterans of America thanks this Subcommittee for your leadership in holding this hearing today on a most serious concern within our veterans’ community.
Each month hundreds of active duty troops, reservists and National Guard members return to their families and communities from deployment in Iraq and Afghanistan. Given the demanding and traumatizing environments of their combat experiences, many veterans experience psychological stresses that are further complicated by substance use and related disorders. In fact, research studies indicate that veterans in the general U.S. population are at increased risk of suicide.
Moreover, according to the results of a National Survey on Drug Use and Health report issued by SAMHSA in November 2007, among veterans of the wars in Iraq and Afghanistan who received care from the Department of Veterans Affairs between 2001 and 2005, nearly one third were diagnosed with mental health and/or psychosocial problems and one fifth were diagnosed with a substance use disorder (SUD). Substance dependence or abuse includes such symptoms as withdrawal, tolerance, use in dangerous situations, trouble with the law, and interference in major obligations at work, school, or home during the past year. Individuals who meet the criteria for either dependence or abuse are said to have a SUD.
In this NSDUH report, combined data from 2004 to 2006 indicate that an annual average of 7.0 percent of veterans aged 18 or older (an estimated 1.8 million persons annually) experienced serious psychological distress (SPD) in the past year. Veterans aged 18 to 25 were more likely to have had an SPD (20.9 percent) than veterans aged 26 to 54 (11.2 percent) or those aged 55 or older (4.3 percent). Female veterans were twice as likely as male veterans to have had an SPD in the past year (14.5 vs. 6.5 percent). And veterans with family incomes of less than $20,000 per year were more likely to have had an SPD in the past year than veterans with higher family incomes
Substance Use Disorders
The combined data from 2004 to 2006 also indicate that an annual average of 7.1 percent of veterans aged 18 or older (an estimated 1.8 million persons) met the criteria for a SUD in the past year. One quarter of veterans aged 18 to 25 met the criteria for a SUD in the past year compared with 11.3 percent of veterans aged 26 to 54 and 4.4 percent of veterans aged 55 or older. There was no difference in SUD between male and female veterans (7.2 vs. 5.8 percent). And veterans with a family income of less than $20,000 per year (10.8 percent) were more likely to have met the criteria for a SUD in the past year than veterans with a family income of $20,000 to $49,999 (6.6 percent), $50,000 to $74,999 (6.3 percent), or $75,000 or more (6.7 percent).
From 2004 to 2006, approximately 1.5 percent of veterans aged 18 or older (an estimated 395,000 persons) had a co-occurring SPD and SUD. Increasing age was associated with lower rates of past year co-occurring SPD and SUD, with veterans aged 18 to 25 having the highest rate (8.4 percent) and veterans aged 55 or older having the lowest rate (0.7 percent). There was no significant difference in co-occurring disorders among males and females (1.5 vs. 2.0 percent, respectively). And veterans with family incomes of less than $20,000 per year were more likely to have had a co-occurring SPD and SUD in the past year than veterans with higher family incomes.
These data can be summarized briefly below --
Combined data from 2004 to 2006 indicate that an annual average of 7.0 percent of veterans aged 18 or older experienced past year serious psychological distress (SPD), 7.1 percent met the criteria for a past year substance use disorder (SUD), and 1.5 percent had co-occurring SPD and SUD.
Veterans aged 18 to 25 were more likely than older veterans to have
higher rates of past year SPD, SUD, and co-occurring SPD and SUD. Veterans
with family incomes of less than $20,000 per year were more likely than
veterans with higher family incomes to have had SPD, SUD, and co-occurring
SPD and SUD in the past year.
The medical, social, and psychological toll from substance abuse disorders is enormous, both for the military and civilian sectors. In the face of such overwhelming damage, two questions emerge: Why does substance abuse receive relatively little medical and public health attention and support compared with other medical conditions? And what can be done to reduce the harm from substance abuse disorders?
Despite their huge health toll, substance abuse disorders remain underappreciated and under funded. Reasons include stigma, tolerance of personal choices, acceptance of youthful experimentation, pessimism about treatment efficacy, fragmented and weak leadership, powerful tobacco and alcohol industries, underinvestment in research, and difficult patients.
Stigma: Despite emerging scientific evidence that substance abuse alters neurotransmitter patterns, many still stigmatize smokers, alcoholics, and drug abusers for having made unwise choices. They feel that even if central nervous system changes result from substance abuse, the choices were wrong in the first place. Another factor is the popular (and spurious) association of substance abuse with minorities. All too often, substance abuse is seen as having a black face, even though differences between blacks and whites in the prevalence of smoking and alcoholism and drug abuse do not support such stereotyping. Finally, public exposure to substance abuse can be polarizing, whether through secondhand smoke, raucous drunks, endangerment by an intoxicated driver, or encounters with aggressive alcoholic or drug-abusing homeless persons.
Civil liberties/free choice: A strong theme of U.S. culture is respect for choice and individual freedom. When the public health evidence is sufficiently compelling -- such as with secondhand smoke or drunk-driving fatalities –regulatory measures can trump that civil libertarian tilt, but usually only after a long struggle.
Tolerance of youthful experimentation: Most
adults experimented in their
Futility/hopelessness: The problems of substance abuse have been around so long that they seem to be intractable. In reality, there has been slow but impressive progress. U.S. smoking rates have declined since 2000, youth smoking is lessening, alcohol-related motor vehicle fatalities have fallen despite major increases in miles traveled, and the prevalence of illicit drug use has fallen.
Pessimism about treatment efficacy: Public officials and clinicians share a double standard about treating substance abuse. Although they embrace aggressive treatment for diseases with miserable prognoses (for example, pancreatic cancer and malignant melanomas), they are skeptical about funding substance abuse treatment in which rates of one-year remissions may vary for smoking and for alcoholism and drug abuse. In clinical settings, this attitude is reinforced by clinicians’ natural reluctance to encounter failures—smokers and drinkers who will not or cannot quit. One reason for this double standard is that substance abuse disorders are seen as volitional, while aggressive cancers are not. And recent data show declines in receipt of substance abuse treatment under private health insurance.
Leadership: In contrast to breast cancer or HIV/AIDS, there are no aroused citizen advocacy groups for substance abuse disorders. The important exceptions of Mothers Against Drunk Driving and Students Against Drunk Driving and DARE stand as lone outliers to this rule. Undoubtedly, stigma makes it difficult for concerned groups to coalesce for public action. Even the most successful citizens group, Alcoholics Anonymous (AA), works undercover by design. Thus, there is no national “race for the cure” against smoking-induced lung cancer and no national mobilized women’s group fighting to stop alcoholism, smoking, or drug abuse.
Fragmentation in the substance abuse field: Not
only is there failure to coalesce among the three categories of substances,
but even within each class there is rivalry, such as tensions between
those who advocate for a twelve-step approach to drug and alcohol treatment
and those who promote pharmaceutical treatment.
Underinvestment in research: Despite the huge toll exerted by tobacco, only a small percent of the National Institutes of Health (NIH) budget is devoted to tobacco research. Similarly, the combined budgets of the National Institute on Drug Abuse (NIDA) and the National Institute on Alcohol Abuse and Alcoholism (NIAAA) amounted to $1.38 billion in 2003, or less than 5 percent of total NIH expenditures.
Difficult patients: Clinicians find it hard to care for patients with substance abuse problems. This reflects the limited education and training most clinicians receive on this topic and disappointment that so few patients follow their advice about quitting. At least in the case of drug-seeking behavior (when patients seek narcotics from physicians), the doctors may stop trusting these patients.
Despite the obstacles noted above, VVA believes that a coordinated workable agenda within the military and the civilian population is possible to lessen the impact of substance use disorders. But this coordinated agenda must include the following –
Better approaches to treatment: Adequate treatment for substance abuse is particularly challenging for America’s uninsured. Even for the insured, many policies, including most Medicaid programs, do not cover the time for counseling or the costs of drugs such as nicotine replacement therapy and bupropion for smoking cessation, methadone for drug addiction, or disulfiram for alcoholism.
As new, effective drugs come on the market, patients must have access to them. Clinicians and policymakers need to reframe how “successful treatment” is defined. Physicians caring for patients with asthma or diabetes understand that these are chronic illnesses and that the goal is to maximize functioning and minimize disability. By contrast, many clinicians become frustrated because it is difficult to “cure” smokers, alcoholics, or drug abusers. Rather than acknowledging that patterns of use often follow a waxing and waning course, that a year of sobriety is cause for triumph and social good, and that it may take many attempts before a patient is able to quit, they too often see the glass as half empty. Envisioning the goal of substance abuse treatment as managing chronic illness—including knowing appropriate referral sources within the community and the roles of non-physician professionals—could help doctors celebrate the tangible benefits of such treatment, instead of lamenting the reality that cures for most chronic diseases are often elusive. Drug courts, which offer treatment as an alternative to incarceration, are a promising but greatly underused resource.
More support for research: Devote 20 percent of the current NIH budget to substance abuse research rather than the current amount. Beyond studying the basic science of addiction and exploring new pharmacologic treatments, research could help us understand why some people who experiment with substances become addicted while others do not, the comparative efficacy of different modes of treatment, the complexities of dual diagnosis (co-occurring mental illness and substance abuse), the social context of addiction, and the impact of various social policies on addiction and the harm it causes.
Better education of health professionals: Substance abuse receives minimal notice in undergraduate and graduate medical education, specialty board certifying exams, continuing medical education, standard clinical textbooks, and medical journals. Not only is content slighted, but it is rare for medical education to acknowledge the role of other health professionals in treating substance abuse or the workings of twelve-step programs such as AA. This relative under-emphasis reflects the reality that few medical faculty work in the area of substance abuse. The neglect is disappointing, given the extent to which substance abuse accounts for illness in Veterans Affairs (VA) and county hospitals—sites of intensive medical education for most academic medical centers.
Nongovernmental funding: Although government will continue to provide the bulk of substance abuse treatment and research dollars, there are gaps in its funding. Some interventions—such as needle exchanges for heroin addicts as a way to reduce the transmission of HIV and hepatitis—may challenge strongly held ideological views, thus precluding government support. Also, the power of the tobacco and alcohol industries may deter adoption of proven public health strategies such as raising cigarette taxes or lowering the permissible blood alcohol level for drivers. Because there are areas where government either will not or cannot take a stand, private support matters. Examples are the role of the ACS and the Robert Wood Johnson Foundation in establishing the CTFK, the counter-marketing of the American Legacy Foundation and the Partnership for a Drug-Free America, and the Conrad N. Hilton Foundation’s support for substance abuse educational programs in public schools.
Stronger leadership Needed: Greater recognition of substance abuse as a major health problem should encourage broader and more diverse leadership. Whether that leadership can or should transcend the individual substance categories is not clear. It may be that lumping together marijuana, beer, cigarettes, and heroin is too unwieldy to generate a unified constituency. Although substance abuse affects women’s health, it has yet to surface on the advocacy agenda of the many women’s organizations.
Drug policies: Providing adequate treatment for community-based and incarcerated people with drug addiction generates social and medical savings: lower crime, lower prison spending, less family dysfunction, and better health. A RAND report of mandatory minimum sentences for cocaine concluded that dollar for dollar, treatment is fifteen times more effective than incarceration in reducing serious crime. Another study showed that treatment for substance abuse in criminal justice settings lowers re-incarceration rates. Also, providing clean needles for heroin addicts reduces the transmission of blood-borne diseases.
Reform of the criminal justice system for substance abuse: Federal and state legislation imposes mandatory terms for possession of illicit drugs, thereby removing sentencing discretion from the hands of judges. Greater flexibility would reduce the cost and burden of incarceration and give many a chance for rehabilitation. Despite evidence that providing treatment and drug testing instead of incarceration can reduce both penal and social costs and increase the rate of drug rehabilitation, these approaches remain rare. Expansion will require permissive laws and knowledgeable judges. State corrections officials estimate that 70–85 percent of inmates need some level of substance abuse treatment. But in approximately 7,600 correctional facilities surveyed in 1997, less than 11 percent of the inmates were in drug treatment programs. Requiring substance abuse treatment as a condition of parole has been shown to increase treatment as well as abstinence from drug use.
Substance abuse remains a serious medical, public health, and social problem. Yet it lacks champions, is under-funded, and is relatively neglected by clinicians and the medical establishment. Despite some real progress in the past decade, the United States still lags behind virtually every developed country in measures of health status. Our current national strategy to close that gap involves funding biomedical research to yield new treatments and improving access to care for
Everyone, including America’s veterans. Both are worthwhile goals but are doomed to failure unless they are coupled with effective policies to reduce harm from substance abuse.
Thank you again for the opportunity to offer our views on this issue and I shall be glad to answer any questions.
VIETNAM VETERANS OF AMERICA
The national organization Vietnam Veterans of America (VVA) is a non-profit veterans' membership organization registered as a 501(c) (19) with the Internal Revenue Service. VVA is also appropriately registered with the Secretary of the Senate and the Clerk of the House of Representatives in compliance with the Lobbying Disclosure Act of 1995.
VVA is not currently in receipt of any federal grant or contract, other than the routine allocation of office space and associated resources in VA Regional Offices for outreach and direct services through its Veterans Benefits Program (Service Representatives). This is also true of the previous two fiscal years.
For Further Information, Contact:
Thomas J. Berger, Ph.D.
Dr. Tom Berger is a Life Member of Vietnam Veterans of America (VVA) and founding member of VVA Chapter 317 in Kansas City, Missouri. He currently serves as National Chair of VVA’s PTSD and Substance Abuse Committee. As such, he is a member and Chair of the Veterans’ Healthcare Administration’s (VHA) Consumer Liaison Council for the Committee on Care of Veterans with Serious Mental Illness (SMI Committee), the Executive Committee of the Mental Health Quality Enhancement Research Initiative Depression Work Group (MHQUERI), and the South Central Mental Illness Research and Education Clinical Center (SC MIRECC). In addition, Dr. Berger holds the distinction of being the first representative of a national veterans’ service organization to hold membership on the VHA’s Executive Committee of the Substance Use Disorder Quality Enhancement Research Initiative (SUD QUERI). Dr. Berger also serves as a reviewer of research proposals for DOD’s “Congressionally Directed Medical Research Programs”. He is a member of VVA’s national Health Care, Government Affairs, Agent Orange and Toxic Substances and Women Veterans committees. At the local level he serves as a Board member and Secretary of the Missouri Vietnam Veterans Foundation and as both President and Secretary of Welcome Home, Inc., a non-profit domiciliary for veterans suffering from PTSD and substance abuse, located in Columbia, Missouri.
Dr. Berger served as a Navy Corpsman with the 3rd Marine Corps Division in Vietnam, 1967-68. Following his military service and upon the subsequent completion of his postdoctoral studies, he held faculty and administrative appointments at the University of Kansas in Lawrence, the State University System of Florida in Tallahassee, and the University of Missouri-Columbia, as well as program administrator positions with the Illinois Easter Seal Society and United Cerebral Palsy of Northwest Missouri. His professional publications include books and research articles in the biological sciences, wildlife regulatory law, adolescent risk behaviors, and post-traumatic stress disorder.
Dr. Berger now devotes his efforts full-time to veterans’ advocacy at the local, state and national levels on behalf of Vietnam Veterans of America. He presently resides in Columbia, Missouri and his hobbies are cycling, music, cooking, and reading.
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