[House Hearing, 116 Congress]
[From the U.S. Government Publishing Office]
DRAFT LEGISLATION INCLUDING H.R. 100, H.R. 712, H.R. 1647, H.R. 2191
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HEARING
BEFORE THE
SUBCOMMITTEE ON HEALTH
OF THE
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED SIXTEENTH CONGRESS
FIRST SESSION
__________
TUESDAY, APRIL 30, 2019
__________
Serial No. 116-7
__________
Printed for the use of the Committee on Veterans' Affairs
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Available via the World Wide Web: http://www.govinfo.gov
__________
U.S. GOVERNMENT PUBLISHING OFFICE
38-957 WASHINGTON : 2021
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COMMITTEE ON VETERANS' AFFAIRS
MARK TAKANO, California, Chairman
JULIA BROWNLEY, California DAVID P. ROE, Tenessee, Ranking
KATHLEEN M. RICE, New York Member
CONOR LAMB, Pennsylvania, Vice- GUS M. BILIRAKIS, Florida
Chairman AUMUA AMATA COLEMAN RADEWAGEN,
MIKE LEVIN, California American Samoa
MAX ROSE, New York MIKE BOST, Illinois
CHRIS PAPPAS, New Hampshire NEAL P. DUNN, Florida
ELAINE G. LURIA, Virginia JACK BERGMAN, Michigan
SUSIE LEE, Nevada JIM BANKS, Indiana
JOE CUNNINGHAM, South Carolina ANDY BARR, Kentucky
GILBERT RAY CISNEROS, JR., DANIEL MEUSER, Pennsylvania
California STEVE WATKINS, Kansas
COLLIN C. PETERSON, Minnesota CHIP ROY, Texas
GREGORIO KILILI CAMACHO SABLAN, W. GREGORY STEUBE, Florida
Northern Mariana Islands
COLIN Z. ALLRED, Texas
LAUREN UNDERWOOD, Illinois
ANTHONY BRINDISI, New York
Ray Kelley, Democratic Staff Director
Jon Towers, Republican Staff Director
SUBCOMMITTEE ON HEALTH
JULIA BROWNLEY, California, Chairwoman
CONOR LAMB, Pennsylvania NEAL P. DUNN, Florida, Ranking
MIKE LEVIN, California Member
ANTHONY BRINDISI, New York AUMUA AMATA COLEMAN RADEWAGEN,
MAX ROSE, New York American Samoa
GILBERT RAY CISNEROS, Jr. ANDY BARR, Kentucky
California DANIEL MEUSER, Pennsylvania
GREGORIO KILILI CAMACHO SABLAN, W. GREGORY STEUBE, Florida
Northern Mariana Islands
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Veterans' Affairs are also
published in electronic form. The printed hearing record remains the
official version. Because electronic submissions are used to prepare
both printed and electronic versions of the hearing record, the process
of converting between various electronic formats may introduce
unintentional errors or omissions. Such occurrences are inherent in the
current publication process and should diminish as the process is
further refined.
C O N T E N T S
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Tuesday, April 30, 2019
Page
Draft Legislation Including: H.R. 100, H.R. 712, H.R. 1647, H.R.
2191........................................................... 1
OPENING STATEMENTS
Honorable Julia Brownley, Chairwoman............................. 1
Honorable Meuser, Ranking Member................................. 3
WITNESSES
The Honorable Earl Blumenauer, U.S. House of Representatives, 3rd
District; Oregon............................................... 4
The Honorable Lou Correa, U.S. House of Representatives, 46th
District; California........................................... 5
Prepared Statement........................................... 35
The Honorable Conor Lamb, U.S. House of Representatives, 17th
District; Pennsylvania......................................... 7
Prepared Statement........................................... 35
The Honorable Max Rose, U.S. House of Representatives, 11th
District; New York............................................. 8
Dr. Keita Franklin, National Director of Suicide Prevention,
Office of Mental Health and Suicide Prevention, U.S. Department
of Veterans Affairs............................................ 9
Prepared Statement........................................... 36
Accompanied by:
Dr. Tracy Gaudet, Director, Office of Patient Centered Care,
U.S. Department of Veterans Affairs
Dr. Larry Mole, Chief Consultant Population Health, U.S.
Department of Veterans Affairs
Ms. Joy Ilem, National Legislative, Director, Disabled American
Veterans....................................................... 12
Prepared Statement........................................... 41
Mr. Carlos Fuentes, Director, National Legislative Service,
Veterans of Foreign Wars....................................... 13
Prepared Statement........................................... 45
Ms. Stephanie Mullen, Research Director, Iraq and Afghanistan
Veterans of America............................................ 15
Prepared Statement........................................... 47
MATERIALS SUBMITTED FOR THE RECORD - UPON REQUEST
Draft Bill, Suicide Notification................................. 50
Draft Bill, Suicide Prevention................................... 50
Draft Bill, VA Whole Health...................................... 50
Draft Bill, Hon. Steube.......................................... 50
H.R. 100......................................................... 50
H.R. 712......................................................... 50
H.R. 1647........................................................ 50
DRAFT LEGISLATION INCLUDING H.R. 100, H.R. 712, H.R. 1647, H.R. 2191
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Tuesday, April 30, 2019
Committee on Veterans' Affairs,
U. S. House of Representatives,
Washington, D.C.
The Subcommittee met, pursuant to notice, at 10:00 a.m., in
Room 2253, Rayburn House Office Building, Hon. Julia Brownley
[Chairman of the Subcommittee] presiding.
Present: Representatives Lamb, Brindisi, Rose, Cisneros,
Peterson, Dunn, Radewagen, Barr, Meuser, and Steube.
OPENING STATEMENT OF JULIA BROWNLEY, CHAIRWOMAN
Ms. Brownley. Good morning. Thank you all for being here,
and welcome to the Subcommittee on Health's first hearing of
the 116th Congress.
First, I would like to thank all of you who were present at
our suicide prevention hearing yesterday, last night. I
appreciate everyone's commitment to tackling the issue. And
today's hearing is another important step in our efforts to end
the epidemic of veteran suicide. I believe we had productive
dialogue on the subject yesterday and I look forward to our
continued discussion today.
In the 116th Congress, the Health Subcommittee's key focus
is ensuring equitable access to high quality health care for
our Nation's heroes. The Veterans Health Administration is the
largest integrated health care system in our country, serving
over 9 million enrolled veterans annually at over 170 medical
centers nationwide. It is vital that we ensure VHA is meeting
the health care needs of these deserving veterans.
I am also committed to ensuring rigorous oversight of the
VA's implementation of community care under the Mission Act,
enacted in the 115th Congress. As VA rolls out this program, it
is crucial that it is well implemented to ensure that veterans
have access to the care they need, while also preserving the
unparalleled services that only the VA can provide.
Chairman Takano has given our Committee an important goal
with his VA 2030 vision, and it will be the duty of this
Subcommittee to identify and carry out the objectives within
our jurisdiction. I intend to make this Subcommittee a
bipartisan and collaborative body and I encourage my colleagues
on both sides of the aisle to share with me their thoughts and
concerns.
That brings me to the work before us. Today, we are holding
the first Health Subcommittee legislative hearing of the 116th
Congress. We will consider eight pieces of legislation,
including discussion on three important areas: suicide
prevention and mental health, cannabis, and whole health
programs.
Each year, roughly 6,000 veterans commit suicide. Each and
every one of these lives lost represents a heartbreaking
tragedy. Many of these veterans were not enrolled in VA health
care. We must ask how VA can better assist those currently
enrolled and how it can better reach those not enrolled, and
how can VA partner with different government agencies and
community partners to expand its public health approach model
for suicide prevention.
As we discussed last night, the tragedy of veteran suicide
is not just a VA problem, but rather a topic that needs to be
addressed through partnerships across agencies and community
resources to provide the best possible services to our
veterans. To that end, we will be discussing four bills today
to enhance VA suicide prevention and mental health programming.
In addition to these four bills, we will discuss three
proposed bills on cannabis. Thirty-three states, to include my
home state of California, have now legalized medicinal
cannabis. The bills being discussed today will help VA, a
national leader in health research, conduct research on health
care benefits of cannabis for veterans and ensure health care
providers and veterans can have informed conversations about
the use of cannabis, while abiding by state level cannabis
programs so that veterans in these 33 states have access to the
same health care treatment that their civilian counterparts
have access to.
Last, but surely not least, the final bill for discussion
today will be centered around VA's whole health program. In May
2018, VA designated 18 whole health flagship sites and 13
additional whole health design sites, which promote a whole
veteran approach to health and centered around what the veteran
finds important to his or her--
The whole health bill introduced by Vice-Chairman Lamb will
ask the VA to generate a report to Congress on the
implementation, utilization, and efficacy of VA's whole health
program. As chair of this Health Subcommittee, I am truly proud
of the work we are doing here today, and I am especially proud
of the way we are doing it in a bipartisan manner.
In closing, I would like to thank our witnesses for
appearing and I look forward to your testimony. With that, I
would like to recognize Mr. Meuser, who is standing in for
Ranking Member Dunn, who I understand will be arriving here
shortly for opening remarks he may wish to make.
Mr. Meuser. Thank you.
Ms. Brownley. You are recognized.
OPENING STATEMENT OF MEUSER, RANKING MEMBER
Mr. Meuser. Thank you, Chairwoman Brownley, very much. Yes.
Ranking Member Dr. Dunn is on his way. It is a pleasure to be
here with you at our vest first Subcommittee on Health hearing
of the 116th Congress. I hope that we will have a productive 2
years and that our work will continue to represent the spirit
of patriotism and bipartisanship that veterans embody.
On that note, we do want to note that our disappointment--
we do have disappointment that the agenda for today's
legislative hearing was developed without any input from the
minority. There are a number of worthy proposals from our
colleagues on both sides of the aisle that Ranking Member Roe
and I would like to see considered this morning.
However, our request to include them in today's hearing
were, in fact, denied. One of them is Dr. Roe's bill, H.R.
1812, that would expand eligibility to Department of Veterans
Affairs vet centers to members of the National Guard, Coast
Guard, and Reserves. As was discussed in detail at last night's
Full Committee hearing, approximately 20 servicemembers and
veterans die by suicide every day. Approximately four of those
suicide deaths occur among members of the National Guard or
Reserve who were never deployed and are not eligible for VA
care. Ensuring that those individuals are able to access
readjustment counseling services could literally be lifesaving.
Given that, and that four of the eight bills we will be
discussing this morning are similarly aimed at preventing
suicide among our military and veteran populations, a priority
we all share, it is a shame that Dr. Roe's proposal is also--is
not also up for discussion today. I certainly hope that this
was a one-time oversight and that we can return to a more
collaborative working relationship moving forward.
That said, I am grateful to all of our witnesses for being
here this morning and we look forward to receiving input on the
proposals before us. With that, I yield back.
Ms. Brownley. Thank you, Mr. Meuser, and I just will add
that we have several Republican bills before us today, and Dr.
Roe's bill or any other bills for that matter, doesn't mean
that they have been rejected. We are just not hearing them
today. So I appreciate your comments.
And we have two great panels joining us today. And I thank
each of you for joining us in what we hope to be a fruitful
discussion on these eight bills. For the first panel, we have
Representative Blumenauer from Oregon; next, we have
Representative Brindisi from New York; next, we have
Representative Correa from California; next, we have
Representative Lamb from Pennsylvania; Representative Rose is
from New York; and last, but surely not least, we have
Representative Steube from Florida.
With that, I now recognize Representative Blumenauer for 5
minutes.
STATEMENT OF HONORABLE EARL BLUMENAUER
Mr. Blumenauer. Thank you very much, Madam Chair. And it is
a pleasure to be here. I wanted to focus in particularly as it
relates to the issue of cannabis and our veterans. You have
rightly identified truly a tragedy in terms of what has
happened to our veterans in terms of suicide, pain management,
a series of things.
We are convinced that there is an opportunity in the area
of medical cannabis to make a difference. I am pleased that in
the past, we have been able to move things along, advancing,
demonstrating majority support on the--this is the first time
we have had a hearing like this with a substantive Committee,
the authorizing Committee, not just appropriations.
One of the great tragedies of our time is the failure to
adequately address the needs of veterans returning home from
Iraq and Afghanistan. We sent more than two million brave men
and women to fight under very difficult circumstances, to say
the very least. And while there continue to be debate about the
wisdom of entering these wars, we can all agree on the need to
provide the care to those veterans as they return home with
wounds that are most visible and in some cases unseen.
And it is no secret that our VA facilities have struggled
to absorb these returning veterans, which coincided with a
national opioid epidemic. And of course, it is not just
veterans. Opioids steal the lives of 115 Americans every day,
more than 30,000 were killed last year.
As veterans with PTSD, chronic pain, and any number of
ailments are looking for relief, lethal opioid overdoses among
VA patients are almost twice the national average. We are doing
something wrong. This is a time when an overwhelming number of
veterans tell me that cannabis has reduced PTSD symptoms, their
dependency on addictive opioids.
We have seen evidence that medical cannabis can be a less
addictive way to manage pain and other symptoms currently
treated with opioids. The National Academy of Science and
Medicine recently confirmed the efficacy of medical cannabis
for chronic pain in adults. Another study in the journal
``Pain'' found no evidence of serious side effects among
medical cannabis users after a year of treatment. A study
published in ``JAMA, the Internal Medicine'' found states with
medical cannabis saw a 24 percent reduction in opioid overdose
deaths. Currently, 47 states, the District of Columbia, and
most territories have passed some laws that provide for legal
access to medical cannabis in some form.
Well over one million patients across the country,
including many veterans, now use cannabis on the recommendation
of their physicians to treat conditions ranging from seizures,
glaucoma, anxiety, chronic pain, nausea, and PTSD. Yet, the VA
official policy prevents the doctors who know the veterans best
from recommending medical cannabis to our veterans, even in
states where it is legal.
As a result, veterans are forced outside the VA system to
seek a simple recommendation for treatment for these
conditions, or any eligible conditions granted to them by state
law, or even consult with them about it. The Veterans Equal
Access Act that I have introduced would reverse this policy and
allow VA health care providers to provide recommendations and
opinions regarding treatment that is legal in their--the
veteran in a state where medical cannabis program is
authorized.
Veterans should not be forced outside the VA system to seek
a treatment that is legal in their state. VA physicians should
not be denied the ability to offer recommendations they think
may meet the needs of their patients. And I hope my colleagues
will join me in supporting this effort.
It is no secret I have been working on this issue for a
number of years. I have talked literally to thousands of people
about medical cannabis, including veterans, who tell me some of
the most heartwarming stories. I appreciate the Subcommittee's
attention to this. This is something that is overwhelmingly
supported by the American public. Survey research suggests in
the range of 90 percent. In your home state of California, you
had a very visible example at the polls. In Florida, it was
over 70 percent that approved it.
It is time for the Federal government and the VA to keep
pace with what the American public wants and an opportunity to
make the lives of our veterans better. Thank you very much.
Ms. Brownley. Thank you, Mr. Blumenauer. And this is an
important bill. Thank you for bringing it forward and as you
said, as you hear from your veterans, I hear from mine as well.
So thank you very, very much for your bill.
I don't see Mr. Brindisi, so we will move Representative
Correa from California. Mr. Correa.
STATEMENT OF HONORABLE LOU CORREA
Mr. Correa. Thank you, Madam Chair and Ranking Member Dr.
Dunn. It is good to see both of you. I want to start off by
thanking our veterans for your service to our country and for
your sacrifice, not only of you and your families. Thank you
again, Ms. Brownley and Mr. Dunn, for your invitation to appear
before you today. I appreciate the opportunity to testify about
this bipartisan legislation written by myself and Mr. Higgins,
H.R. 712, The VA Medical Cannabis Research Act.
As you know, veterans experience physical and psychological
injuries at a higher rate than their civilian counterparts as a
result of their military service to our country. Unfortunately,
the current treatment of prescription opioids to address PTSD
and chronic pain has, at times, been ineffective. And this had
dangerous results, such as addiction or even death.
In response to this crisis, Congress correctly and the VA
have joined other national organizations trying to figure out
how to reduce veterans' addiction of opioids. Twenty veterans a
day commit suicide. We have got to find better ways of
addressing the needs of our veterans.
Solution. Over the years, when I was in California sitting
on the Veterans' Affairs Committee, chairing Veterans' Affairs,
I used to get a stream of veterans coming to me and quietly and
privately asking, ``Can we use cannabis? Can the VA prescribe
cannabis for us? Can we talk to our doctor at the VA about
cannabis without losing our VA benefits?'' And of course, the
answer is, ``Yes, you can talk to your cannabis--about cannabis
with your doctor at the VA, but the problem is, there is nobody
at the VA that can give you information about how cannabis can
benefit you.''
Time went on. We recently had two polls, one by the
Afghanistan Veterans of America, 80 percent of those veteran's
support cannabis research, support looking at the cannabis for
veterans. The American Legion did another poll, 92 percent of
those veteran's support research and the cannabis treatment of
veterans and their invisible wounds.
Solution. This bill. This bill requires the VA to conduct
double digit blind clinical test trials on the impact of
different forms of cannabis and delivery methods of cannabis on
specific health conditions of eligible veterans with PTSD and
chronic pain.
Madam Chair, Members of this Committee, a few years ago
after the veterans came to me in my district and said, ``Lou,
we want you to talk to us about cannabis,'' I started visiting
different cannabis groups in my district. One of them was a
cannabis shop. Legal, medical cannabis shop in my district. I
went and I asked the lady at the counter, I said, ``Tell me
what it is that you do to talk to folks that come to you to ask
for medical cannabis. How do you prescribe different cannabis
strengths for them?''
She started telling me what she did, and I said, ``Ma'am,
what are your qualifications? What is it that got you qualified
to talk to patients about cannabis?'' And she said, ``I have
been using cannabis for 20 years.'' Those were her
qualifications. And I say to all of you here, it is time to
move on. It is time to do research. It is time to make sure
that our veterans get to know what cannabis is good for and
what cannabis is not good for. We need medical research.
And that is why I brought this legislation forth to simply
tell our veterans what cannabis is good for. We owe our
veterans a tremendous amount, the least we can do is make sure
we are giving them their proper treatment for those invisible
wounds that they brought back from the battlefield. Thank you
very much.
[The prepared statement of Lou Correa appears in the
Appendix]
Ms. Brownley. Thank you, Mr. Correa, and we miss you on the
Committee, but very happy that you are continuing to persevere
and one of your priorities that I know has been a priority for
you and so thank you for continuing on and I agree, we need to
push the VA forward on this issue.
Mr. Correa. Madam Chairperson, I miss being on this
Committee. I think it is that one place in Congress that both
Democrats and Republicans come together to do what is right for
all veterans.
Ms. Brownley. Thank you very much. I now recognize Mr. Lamb
for 5 minutes.
STATEMENT OF HONORABLE CONOR LAMB
Mr. Lamb. Thank you, Madam Chairwoman. And before I get to
my bill, I just want to thank Representative Blumenauer and
Representative Correa for their efforts and for really leading
the way on this issue. You know, we say all the time that
veterans deserve the best when it comes to health care and
medical treatment. And I think part of what that means is that
we have to look at the VA as an institution that can lead, that
can break new grounds, that can cross these frontiers. And when
there is innovation and reform in health care, we need to be at
the front, not behind, not entrenched in the old way of doing
things. And I think these are some great efforts to try to help
us move forward on an issue that can get veterans better
treatment, that can attract a better workforce, that actually
wants to be able to prescribe these treatments that they know
work. And so I thank you for your efforts.
The whole health bill that I am introducing is really in
the same vein. In a lot of areas of American health care right
now, we are seeing experimentation with a wider array of
traditional and non-traditional treatments. Anything from
incorporating chiropractic services, massage, acupuncture, to
just whole health coaching, in diet, in nutrition, and sleep,
acupuncture, meditation, yoga. I mean, tai chi. There are all
of these things out there and different practices work for
different people.
So the idea of this bill is that we would like the VA to
look at the places where their whole health program is in
effect right now. Tell us how it is doing, but more
importantly, tell us what the availability in access is across
the VA system for veterans and where there is no access in
availability and help us figure out how we can expand it.
I had the opportunity last year to visit the whole health
program at Washington, D.C., which is one of, I believe, about
18 or so places that they have the whole health program in
place. And what you saw there were patients who were happy, and
successful, and felt like they had some measure of control over
their own health care. And that is the biggest thing.
We talk about the practices themselves, you know, the way
that yoga can help someone who is dealing with chronic pain.
That is good. But what struck me as even better is that we were
giving veterans an array of options, and the ability to try a
few different ones and see what works. And when I--I remember
asking an older Vietnam veteran that was there, ``Do you like
this program?'' ``Yes, of course, I do.'' ``Why do you like
it?'' And he was like, ``Because I get to pick. I get to pick
which classes I come to, and how often, and it doesn't cost me
anything. And if I like one of the instructors, and I like the
other people who come to the class, I can keep coming back.''
And they get to know each other.
And there is plenty of research that shows why that is a
better way to do health care, when someone feels like they have
control over it, it is just going to work better, but I think
we all know that. It is common sense.
So that is what is behind this bill, the Whole Veteran Act
introduced by myself and my colleague, Mr. Ryan, from Ohio. So
I appreciate everybody's support that can get behind it, and I
think we can do some great things to help veterans and push the
frontier of how we are doing health care going forward. Thank
you, Madam Chairwoman. I yield back.
[The prepared statement of Conor Lamb appears in the
Appendix]
Ms. Brownley. Thank you, Mr. Lamb, and again thank you for
bringing this important bill forward. And I now recognize Mr.
Rose for 5 minutes.
STATEMENT OF HONORABLE MAX ROSE
Mr. Rose. Thank you, Madam Chairwoman, and thank you
Ranking Member Dunn, and just to reiterate my friend Conor's
statements, I know Representative Blumenauer left, but Rep.
Correa, thank you for your leadership on this issue as well.
As a more recent vet, and someone who still serves in the
Guard, we need to utilize all tools available to us to deal
with folks as they are still encountering the wounds of combat
and of service. So thank you again.
I, like many veterans, as I am, the issue under discussion,
that of veteran suicide, is personal. Based on recent events,
it is clear that this mental health crisis requires action,
both on the part of Members of Congress, and certainly on the
part of the VA.
The rising rate of veteran suicide is beyond a tragedy.
Every veteran who struggles with mental health issues, physical
scars of war, and who dies by suicide is another casualty of
combat. And they are a casualty of combat, and of war, and of
their service irrespective of whether they deployed to war or
not. And we are noticing a truly jarring phenomenon: veterans
attempting or completing suicide on VA campuses, four veterans
just this month alone lost their lives to suicide within a VA
facility or on VA grounds.
Something must be done about this and we need to do it now.
A thorough, multi-faceted approach is required to not only
assess whether the services these veterans received were
adequate, but to make sure that the VA has the framework to
provide the necessary data to Congress and to other appropriate
entities.
That is why my legislation, I am proposing the Fostering
Intergovernmental Health Transparency and Veteran Suicide Act,
or Fight Veteran Suicides Act is a key first step. This bill
would make sure the VA reports critical information to Congress
when these events occur and requires these metrics quickly.
Having these data points would help Congress fully
understand the scope of this crisis. You know, as I have said
time and time again, we need all of the information necessary
so we can better serve our fellow veterans in need, while
ensuring the VA has the necessary tools and resources to tackle
this trend properly. I would like to thank AMVets, Paralyzed
Veterans of America, the Reserve Officers Association, the
Military Order of the Purple Heart, as well as the Disabled
American Veterans here with us today for their support of this
bipartisan legislation. And I strongly urge my colleagues to
support it as well. Thank you for addressing this and I yield
back the balance of my time, Madam Chairwoman.
[The prepared statement of Max Rose appears in the
Appendix]
Ms. Brownley. Thank you, Mr. Rose. And thank you also for
bringing this bill forward. I think the suicides that we have
all witnessed on VA campuses, in my mind, is a cry for help.
And I think that is what last night was about. And I think your
bill, in terms of reporting, is extraordinarily important. So
thank you for bringing it forward.
And I will say thank you to the first panel, and we will
have a little transition period here where we set up the second
panel. And when that happens, I will introduce the second
panel. Thank you very much.
Ms. Brownley. I now recognize the second panel. And we have
Dr. Keita Franklin, national director of suicide prevention
from the Department of Veteran Affairs. Dr. Franklin is
accompanied by Dr. Tracy Gaudet, director of patient centered
care and Dr. Larry Mole, chief consultant population health.
Next, we have Joy Ilem, national legislative director of
Disabled American Veterans. And also here is Carlos Fuentes,
national legislative director at Veterans of Foreign Wars. Last
but not least, we have Jeremy Butler, chief executive officer
at Iraq and Afghanistan Veterans of America. Wrong person. I am
sorry. We have Stephanie Mullen. I apologize. It is a good
reason to look up, as opposed to--we have Stephanie Mullen,
chief--from the Iraq and Afghanistan Veterans of America.
With that, I now recognize Dr. Keita Franklin for 5
minutes. Dr. Franklin.
STATEMENT OF DR. KEITA FRANKLIN
Ms. Franklin. Good morning, Chairwoman Brownley, Ranking
Member Dunn, and Members of the Subcommittee. Thank you for
inviting us here today to discuss a number of important bills
about mental health and suicide prevention, as well as VA
policy on veteran participation in state approved marijuana
programs, and cannabis research, and whole health.
Madam Chair, before turning to the specific bills, I want
to emphasize that suicide prevention is a top priority in the
Department. I think you heard that last night. Suicide is
complex. It is a serious national public health issue that
affects people from all walks of life, not just veterans, and
for a variety of reasons. And while there is much to learn, we
know that it is preventable. We know that treatment works, and
that there is hope. And I want to thank you for your leadership
on this issue.
Although VA is creating the path forward, we know that one
agency alone cannot solve the issue. Preventing suicide
requires bundled approaches, working across multiple sectors.
And our work is guided by the national strategy for preventing
veteran suicide. This strategy published in 2018 expands beyond
crisis intervention and provides a framework for identifying
the priorities, organizing efforts, and focusing resources
through a broad public health approach, with an emphasis on
comprehensive community level engagement. It is a plan for what
we can all do to work together to prevent veteran suicide
across the entire Nation, not just within the four walls of the
VA.
Legislatures play an important role in this integrated
approach, not only because of the importance of policy
interventions, but also in your ability to reach out across the
Nation. For example, as you may know, this month we started
working with you and other Members of Congress to spread
awareness about this important topic through a PSA drive on
Capitol Hill. Again, we want to thank all of you that have
already developed your PSAs, and for your continued support and
concern for this important issue of veteran suicide.
So just turning right to the bills that are presented
today. These are complex issues. They call for multi-layered
solutions that require a rigorous level of review and analysis.
And we provided some of our views in our written statements and
we are prepared to continue that conversation today. And I will
jump right in with the Veteran Overmedication and Suicide
Prevention Act of 2019.
This bill calls for the VA to partner with the national
academies and to conduct in-depth, post mortem data analysis.
Data and surveillance are at the core of our comprehensive
public health approach and they inform our suicide prevention
efforts and our partnerships with agencies like the National
Academy are an essential piece to what we do.
We appreciate Congress' interest in advancing those
partnerships and in furthering how suicide data is collected,
analyzed, and reported. VA was one of the first institutions to
implement a comprehensive suicide surveillance and has
continuously improved data and surveillance related to veteran
suicide.
Part of this bill reflects a specific requirement to
further that analysis that we already do. Other pieces in the
bill involve outside organizations and authorities that we
don't directly own. And therefore, it will make full compliance
with a proposed bill in its existing form very difficult to
implement. Yet we know there is room to improve, and this is
why we are eager to work with the national academies and to
further study this issue. And I do stand ready to work through
any and all details and barriers with this Committee.
Moving to the next piece of legislation related to the
draft suicide notification bill, this would require VA to
submit notification of veteran suicide deaths or suicide
attempts that occur on VA facilities to Congress within 7 days
of the event. The VA supports this legislation. There are few
details that need to be worked out in terms of technical
issues, ensuring that we preserve surviving family members'
privacy and dignity with regard to deaths that occur. But
regardless, we are pleased to work with the Subcommittee on
this initiative.
The two remaining suicide related bills call for GAO review
of suicide prevention, MOAs, and our memorandums of agreement
and understanding, and a review of the role of our suicide
prevention coordinators. VA would defer to the GAO on these
bills. We defer to the GAO on these proposed bills. I would let
the Committee know that we are already in the midst of an in-
depth analysis on both of these issues and I am happy to turn
over and share any of that information with this Committee.
Third, I am moving from the suicide prevention bills to the
piece on cannabis. The VA Medical Cannabis Research Act of 2019
would require VA to conduct a clinical trial to examine a
multitude of health outcomes among veterans with varying
medical diagnoses and would involve multiple strains of
cannabis compositions and routes of administration.
Typically, a smaller early phase trial designs would be
used to advance our knowledge of benefits and risks regarding
cannabis, before moving to a type of more expansive approach,
as described in this proposed legislation. VA is currently
supporting a clinical trial of cannabis for the treatment of
post-traumatic stress disorder. Any trial with human subjects
must include an evaluation of the risks and the safety and
include the smallest number of participants to avoid putting
subjects at increased risk unnecessarily. So and for these
reasons, we don't support this proposed legislation. I do have
Dr. Larry Mole here to talk to you more about that during the
remaining of the hearing.
And then moving to the Veteran Equal Access Act and the
Veteran Cannabis Use for Safe Healing Act. This would authorize
physicians and other health care providers in VA to provide
recommendations, opinions, and for H.R. 1647, the completion of
forms regarding participation in state marijuana programs.
VHA's current policy prohibits VA providers from
recommending and making referrals to or completing paperwork
for veteran participation in state marijuana programs. This
prohibition is the result of the Drug Enforcement Agency,
guidance that is pushed out from that agency, which advised VA
that no provision of controlled--of the Controlled Substance
Act would be exempt from criminal sanctions as a VA physician
who acts with intent to provide a patient with means to obtain
marijuana.
In addition, this proposal would authorize VA providers to
discuss marijuana use with their patients, record that use in
the patient's medical record, and prevent VA from denying a
veteran any benefit for participating in a state approved
marijuana program. Please know that our existing policy in VHA
already permits discussion and documentation, and clearly
states that veterans will not be denied benefits by discussing
this information with a VHA provider. Thus, VA does not support
this bill.
The draft VA Whole Health Bill would require VA to submit
to Congress a report on the implementation of VA's February
1st, 2019 memorandum on the subject of advancing whole health
transformation across VHA. Specifically, this report would
include an analysis of the deployment of whole health services
at 36 facilities. VA supports this draft bill, but notes that
Congress may wish to consider extending the draft bill's
requirement to a VHA-wide enterprise update. In addition, a
thorough research report on veteran outcomes, cost,
utilization, workforce engagement, burnout, and implementation
will be provided to Congress on the 18 facilities currently
deploying all aspects of whole health in March 2021 as required
by the CARA legislation.
Madam Chairwoman, in conclusion, I cannot emphasize enough
the commitment of the secretary and all of the VA to use every
effort to prevent veteran suicide and continue to equip and
empower all veterans with the resources and care that they need
to thrive. We appreciate the Committee's attention to this
issue. We pledge to work hand in hand with the Congress on
innovative and evidence-based approaches to this problem.
This concludes my statement and I am happy to answer any
questions. Myself, my colleagues are here to answer any
questions that any Member of the Committee may have.
[The prepared statement of Keita Franklin appears in the
Appendix]
Ms. Brownley. Thank you, Dr. Franklin. And I now recognize
Joy Ilem for 5 minutes.
STATEMENT OF JOY ILEM
Ms. Ilem. Chairman Brownley, thank you for inviting--and
Members of the Subcommittee, thank you for inviting DAV to
testify at this legislative hearing.
We are pleased to offer our views today on the bills under
consideration by the Subcommittee. In accordance with DAV
resolution number 023, we are pleased to support H.R. 712, the
VA Medicinal Cannabis Research Act of 2019. This bill would
direct the VA to perform clinical research to determine whether
cannabis is able to reduce symptoms associated with chronic
pain, and how it may affect alcohol use or dosage of certain
medications for veterans with PTSD.
We concur that research is necessary to help clinicians
better understand the safety and efficacy of cannabis use for
specific conditions that often co-occur in the veteran
population, such as chronic pain and post-traumatic stress.
DAV also supports the draft measure being considered that
requires GAO to conduct an assessment of the role of VA suicide
prevention coordinators and their responsibilities within the
VA health care system. The study would assess associated
workload, vacancy rates, adequacy and appropriateness of
training, and oversight of these positions and how these
factors may vary across the system.
VHA guidance for delivery of mental health services allows
for local variation and programs and thus, training and
oversight of the suicide prevention coordinator position could
differ somewhat from site to site. Because of these ambiguities
and the importance of the coordinator's responsibilities, DAV
agrees this study could yield important information and thus we
support the draft bill.
The draft measure focused on advanced--VA's whole health
transformation model would require the VA to report on access
and availability on each of several complimentary and
integrative medicine practices. In accordance with DAV
resolution 277, we support veterans' access to a full continuum
of care, including alternative and complimentary care, such as
yoga, massage, acupuncture, chiropractic care, and other non-
traditional therapies.
DAV is aware that some facilities may not offer a full
complement of these types of services or may have to limit the
number of visits for massage therapy or other popular
integrative treatments. The report would help to determine to
what extent these services are available across the system for
veterans that prefer them over more traditional types of care.
To provide a more complete picture, DAV recommends and
suggests that the study also include complementary and
alternative services the VA provides to its veteran's community
care program.
We need to ensure these--DAV supports the draft bill that
would require GAO to report on the effectiveness of VA
memorandum of agreement and memorandum of understanding with
non-VA providers to carry out suicide prevention activities and
mental health case management services.
We need to ensure these agreements hold community partners
accountable for delivering evidence based high quality mental
health services to veterans who need them. Therefore, community
partners or network providers, should be held to the same
competency, training, and quality standards that VA mental
health providers are required to meet.
The draft bill would provide needed oversight of agreements
with non-department entities, providing mental health services
to veterans to determine regional variances and the extent to
which VA tracks health outcomes of such entities.
H.R. 100, the Veterans Overmedication and Suicide
Prevention Act of 2019 calls for a study aimed at identifying
suicides among veterans that may be attributed to
overmedicating patients or inappropriate prescribing patterns
in the VA. DAV supports the intent of the bill and certainly
agrees that research and proper oversight of VA clinical
practices are necessary. But it is difficult to assess if
appropriate treatment protocols were followed without looking
at individual case studies, especially in cases of medically
complex patients with co-occurring physical and mental health
conditions.
For these reasons, we are urge the Subcommittee to consider
working with VA subject matter experts to revise certain
provisions in the bill related to data collection so that it
can better advance the important goals of improving patient
safety, improve poly-pharmacy management, and reducing suicides
among veteran patients.
Finally, DAV has no objection to favorable consideration of
the draft measure requiring VA to notify Congress about any
suicide or attempted suicide of a veteran that occurs on the
grounds or in a VA facility.
Madam Chairwoman, this concludes my testimony. I would be
pleased to respond to any questions from you or other Members
of the Committee. Thank you.
[The prepared statement of Joy Ilem appears in the
Appendix]
Ms. Brownley. Thank you, Ms. Ilem. And I now recognize Mr.
Fuentes for 5 minutes.
STATEMENT OF CARLOS FUENTES
Mr. Fuentes. Chairwoman Brownley, Ranking Member Dunn, and
Members of the Subcommittee, thank you for allowing the VFW to
represent our views on legislation pending before the
Committee. The VFW is proud to support the VA Medicinal
Cannabis Research Act 2019. The VA's reliance on opioids to
treat chronic pain and other conditions has unfortunately led
to addiction, and even death, such as Jason Simcakoski, who
died from an overdose of medications he was prescribed by his
doctors at the Tomah VA Medical Center.
The VFW is proud to have stood next to Jason's family, and
many Members of the Subcommittee, to champion the Jason
Simcakoski Memorial and Promise Act, which required VA reduce
the use of high dose opioids. To its credit, the VA has made
concerted efforts to ensure it properly uses pharmaceutical
treatments under the opioid safety initiative. VA has reduced
the number of patients to whom it prescribes opioids by more
than 22 percent. Now, VA must expand research on the efficacy
of non-traditional alternatives to opioids, such as medicinal
cannabis and other holistic approaches.
VFW members tells us medicinal cannabis works and it is a
more suitable option than the drug cocktails VA prescribes. VA
must research how medicinal cannabis can help veterans cope
with PTSD and other conditions, such as chronic pain. The VFW
and Student Veterans of America fellow, Christopher Lamy, an
Army veteran and LSU law school student, focused his semester
long research project and advocacy efforts on the VA Medicinal
Cannabis Research Act of 2019.
Chris' research discovered that veterans experienced
chronic pain at 40 percent higher rates than non-veterans and
if not properly treated, such chronic pain often leads to
depression, anxiety, and decreased quality of life. Chris also
found that veterans who discuss use of medicinal cannabis with
their doctors are often--often have their medications changed
or discontinued. The fear of reprisal for medicinal cannabis
use prevents veterans from discussing and disclosing
information to their VA health care providers, which can also
lead to drug interaction issues.
This legislation would prohibit VA from denying benefits
based on participation in the study. To ensure participants of
the study do not have their VA health care impacted, the VFW
recommends prohibiting VA doctors from denying or altering
treatment for participants without consultation or concurrence
with such veterans.
The VFW agrees with the intent of the Veterans Equal Access
Act, but cannot offer it support at this time. The VFW agrees
that veterans who rely on the VA health care system must have
access to medicinal cannabis if such therapies are proven to
assist--proven to be effective in assisting and treating
certain health conditions. Without such evidence, the VA would
not have the ability to prescribe or provide medicinal cannabis
to veterans.
It is unacceptable for VA providers to recommend a
treatment that is unavailable to veterans at their VA medical
facilities, which forces those patients to pay the full cost of
such care or rely on other means for those treatments. The VFW
strongly supports the provisions of the Veterans Cannabis Use
for Safe Healing Act that protect veterans from having their
earned benefits eroded or denied simply because they
participate in a state approved marijuana program.
Veterans who participate in such programs must not fear
that VA will take away benefits they have earned and deserve.
However, we cannot support VA providers recommending
participation in state approved marijuana programs if VA is
unable to provide such recommended course of treatment. The VFW
supports the Veteran Overmedication and Suicide Prevention Act
of 2019 and they support for Suicide Prevention Coordinators
Act.
These two bills would make strides to reduce veteran
suicide. Suicide is a serious issue. We must do whatever it
takes to save the 20 veterans who take their own lives every
day. Madam Chairwoman, this concludes my statement. I am happy
to answer any questions you or the Members of the Committee may
have.
[The prepared statement of Carlos Fuentes ppears in the
Appendix]
Ms. Brownley. Thank you, Mr. Fuentes. And I now recognize
Stephanie Mullen, who is the research director for the Iraq and
Afghanistan Veterans of America. Thank you for being here.
STATEMENT OF STEPHANIE MULLEN
Ms. Mullen. Thank you. Thank you, Chairwoman Brownley,
Ranking Member Dunn, and distinguished Members of the
Subcommittee. On behalf of IAVA, and our more than 425,000
members worldwide, I would like to thank you for the
opportunity to testify here today.
As research director for IAVA, I use the collective
experiences and views of IAVA members to support our policy and
programmatic work, giving numbers to the narratives of IAVA
members every day.
This work is personal for me. I come from a military
family, with a mother that served 20 years for this country
while raising a family. Many of the issues IAVA tirelessly
advocates for directly impacts the people I love most, and it
drives my work to ensure that all veterans are receiving the
best care and treatment possible.
Support for veteran medicinal cannabis use is an important
part of our work. And it is why it is one of IAVA's big six
priorities for 2019. For years, IAVA members have been
supportive of medical cannabis. In our latest member survey, 83
percent agree that cannabis should be legal for medical
purposes, and a resounding 90 percent believe cannabis should
be researched for medicinal uses.
IAVA members are calling for cannabis research and it is
past time for the Department of Veterans Affairs to catch up.
This is why IAVA is proud to support the VA Medicinal Cannabis
Research Act, which will advance research and understanding
around the safety and effectiveness of cannabis to treat the
signature injuries of war.
However, research takes time. Years, in fact. And veterans
are suffering from their injuries today. With over 30 states
legalizing medical cannabis, if veterans are unable to go
through VA to get medical cannabis, they will go around it. The
veterans shouldn't feel that they have to hide and circumvent
VA to access a standard of care their civilian counterparts can
access easily.
We know this is already occurring from IAVA members
nationwide. In just the last month, over 100 IAVA members have
shared stories of their cannabis use, with dozens sharing how
VA retaliated against them or mishandled their information. And
dozens more sharing that they flat out refuse to tell VA about
their cannabis use.
While current VA policy allows for clinicians to talk to
their veteran patients about cannabis, VA clinicians are unable
to recommend cannabis to their patients, fill out state
cannabis medical forms, or recommend the best programs and
options for their patients. These limitations have negative
impacts on the overall care of veterans at VA. For these
reasons, IAVA is proud to support the Veterans Equal Access
Act, the Veterans Cannabis Use for Safe Healing Act, and the
Whole Veterans Act.
Though cannabis reform is an important pillar in our
advocacy efforts, the top priority for IAVA and among our
membership is suicide prevention among troops and veterans. In
2016, the latest numbers available, an average of 20
servicemembers and veterans died by suicide each day,
accounting for over 7,000 deaths each year. Each one of these
deaths impacts an entire community, a family, a friend group, a
military unit, and the lives of each and every person that
veteran or servicemember touched.
IAVA members know this well. Fifty-nine percent of our
membership knows a post 9/11 veteran that has died by suicide.
That is a rise of almost 20 percent since just 2014. IAVA
thanks the Subcommittee for highlighting this public health
crisis and we are pleased to support the Veteran Overmedication
and Suicide Prevention Act, the Veterans' Care Quality
Transparency Act, and the Support for Suicide Prevention
Coordinators Act.
Increasing our understanding of veteran suicide, the risk
and protective factors surrounding it, and the effectiveness of
suicide prevention programs at VA are all essential to tackling
this issue.
While we recognize and appreciate the intent regarding
veteran suicides on VA property behind the FIGHT Veteran
Suicide Act, IAVA has some concerns regarding this legislation.
When a veteran dies by suicide on VA property, to include
the tragic veteran suicide just yesterday at the VA in
Cleveland, it indicates that the foundation of trust between
the public and VA has be catastrophically undercut. These
tragic events should be a call to action to ensure that all VA
policies and procedures surrounding VA emergency mental health
care, facility security, and personnel training are up to date,
acceptable, and being implemented correctly. A failure in the
system should and must be addressed.
IAVA recommends that the proposed legislation focused on
these procedures and policies at VA facilities that may be able
to intervene in a moment of crisis, rather than the individual
factors surrounding the tragic event itself.
Members of the Subcommittee, thank you again for the
opportunity to share IAVA's views on the issues today. I look
forward to answering any questions you may have and working
with you in the future.
[The prepared statement of Stephanie Mullen appears in the
Appendix]
Ms. Brownley. Thank you, Ms. Mullen, for your testimony and
thank all of the witnesses as well for your testimony today.
And so we will now begin the question portion of the hearing.
And I will recognize myself for 5 minutes.
I think the first issue I really wanted to address is the
cannabis issue. We have got a couple of bills before us, which
I think are good bills, and the VA doesn't support those bills.
We have the VSOs all speaking in favor of these bills. This
is--you know, this seems to be an issue that has been going on
now for a while, this schism between what the VA believes and
what the VSOs want. And this is a big frustration for me
because I think it is overwhelmingly clear amongst the American
people, and amongst our veterans across the country, that this
is an issue that they are keenly interested in and want to have
access to.
And so I guess my question is, you know, how are we going
to reconcile this? You give particular reasons for why you
don't support this legislation. You know, I can't speak whether
these issues are valid or not, but if they are, how are you
working with the VSOs to kind of work through, not I mean these
two bills, but there are going to be more because of the
interest of our veterans and the interest of the American
people.
So Dr. Franklin, if you could just respond to that.
Ms. Franklin. Sure. I would actually ask Dr. Larry Mole,
our lead in this area, to respond.
Mr. Mole. Good morning, and thanks for the opportunity to
speak today.
I think for VA, the--and we have seen legislation come in
over the last few years and our kind of rate limiting step is
the authority related to being able to recommend or prescribe
is related to the Controlled Substance Act. And as long as
cannabis or marijuana remains a schedule 1 drug, then we are
going to look to the DEA and the Department of Justice to give
us their opinion on what our prescribers are able to do.
And that is kind of, I think, a short summary of where that
process is at. And so I think this Committee can make strong
proposals to us to move forward with recommendations, filling
out forms and such, but at the end, we will need to go back to
DEA and Department of Justice for their opinion. And I have not
seen anything myself that suggests their opinion will change.
Ms. Brownley. And so what role does the VA play in terms of
working with DOJ and DEA? I mean, what kinds of meetings are
you having? What kind of conversations are you having to try to
push the envelope in support of our veterans?
Mr. Mole. I would say there are very few meetings that
occur, and it is because the--and I am not an attorney, so I
can't speak from an attorney's opinion--
Ms. Brownley. Understood.
Mr. Mole [continued]. --but I think they are waiting to see
that something changes from a regulation perspective that then
they would respond to. And that is, I think, the best way I can
summarize it. I mean, we can go to DEA, and Department of
Justice, but they are going to continue to point to the
Controlled Substance Act until there is a change in that act.
Ms. Brownley. And so you can't even do the research on
efficacy because of this?
Mr. Mole. Research is a whole different question. I mean,
and we can get to that. But in terms of the recommending,
prescribing, that is where the Controlled Substance Act is the
authority of what we do.
Ms. Brownley. Okay, thank you. I would like to hear from
the other witnesses in terms of the--your perspective on these
issues.
Mr. Fuentes. Ma'am, thank you very much for bringing these
issues and consider them by the Committee. They are very
important and have the support of the overwhelming majority of
the veterans' community.
I would have to say that I agree--the VFW agrees with the
VA in terms of prescribing something VA can't provide through
its pharmacies, but VA should conduct research on medical
cannabis. The claim and previous testimony has also said that
they have the authority but still haven't done it. CBD is not
medical cannabis, and I encourage VA--the VFW encourages VA to
continue CBD research and do more of it, but it is not exactly
what we are looking for here with this legislation.
Ms. Brownley. Thank you. Any other comments? Ms. Mullen?
Ms. Ilem. I would say, as well, research is the key.
Everyone wants to make sure that these--this medicinal cannabis
would be beneficial to veterans. We want to make sure that
there is no harm done. So the research is the first step to
doing that. And that is essential. But I think even more
importantly, as Stephanie, and we have mentioned, is that
veterans are using this as a medication to try to stem their
symptoms, whether that be from chronic pain, PTSD symptoms, and
others.
So we know that they are doing that, and we have heard some
of repercussions for that happening. And we want to make sure
veterans are safe and have access to all treatments that may be
beneficial to them. So this is a critical piece to move forward
and I hope VA will be able to address on the research side. I
know they mentioned some of that in their testimony about how
things like that are conducted. So that type of research.
Ms. Brownley. Ms. Mullen?
Ms. Mullen. I think that you described the attention
between Federal and state policy well and that tends to be the
biggest factor when we are talking about VA and recommending
cannabis, and allowing it in pharmacies. I do think it is
within the purview of this Committee within Congress to close
some of those loopholes and ensure that VA clinicians, while
maybe not able to recommend it directly, can at least advise
what--where to go for it. What state medical places they should
be looking at, because right now, it is going completely under
the radar.
And again, with the VA policy that is currently in place,
right now, veterans are supposed to be able to talk to their
providers about their cannabis use and it shouldn't be used
against them. I think in practice, that doesn't always occur.
And so having some sort of legislation that would actually
protect veterans would be very helpful.
Ms. Brownley. Dr. Dunn.
Mr. Dunn. Thank you, Madam Chair. So I think the H.R. 712
has engendered a lot of interest here. I would like to address
it. Mr. Mole, you went right to the heart of the problem. I
think that the physicians feel, and that is so there is a
Federal law that makes it illegal, and there are multiple state
laws that make cannabis legal to prescribe and discuss. And yet
the physicians and all the clinicians can be prosecuted under
either state or Federal law. So there is--we are not, I think,
in a position here to actually protect the VA physicians who
want to disburse or prescribe cannabis unless we change that
law.
So we might be looking at the wrong leverage point when we
address these laws without addressing the schedule of the drug
and the actual punitive actions on it. I could not agree with
you more that we ought to be research on this. I think we ought
to change the schedule to schedule 2. It seems like every
Committee I go in, we have another discussion about cannabis.
I was in banking not too long ago. Can we bank people who
sell cannabis? No, we can't. Yes, we can. It depends on if it
is Federal or state law, right? And so the poor person who gets
involved in actually helping patients with this substance,
potentially helping them, you know, can go to jail in any one
of a number of venues.
So thank you for bringing out that what we need to do is
move it from schedule 1 to a schedule 2. And that is the major
objection, right, on the VA's part of that? But let's take a
look at 712, the research very quickly here. You have expressed
reservations on the design of the study, as well as the fact
that it is not a schedule 2 drug. Would you help us redesign
this bill in such a way that the protocol would suit the VA?
Dr. Franklin?
Ms. Franklin. Absolutely. I am sure we would. Yes, sir.
Mr. Dunn. Okay. So you could see a way forward doing
cannabis research, on tetrahydrocannabinol, as well as
cannabidiols, and all those things, as long as we made it legal
for your researchers to do that?
Mr. Mole. Yeah. I would just add that it is legal for our
researchers to research cannabis, cannabidiols, marijuana,
whichever label we want to use and whatever product it is. And
so they are able to do that. That is a folklore that has kind
of been around, unfortunately.
Mr. Dunn. But it is difficult?
Mr. Mole. There are some extra--
Mr. Dunn. It is very controlled drug.
Mr. Mole. There are some extra steps you have to do. But as
Dr. Franklin said, we have one investigator who is funded by VA
right now, down in San Diego.
Mr. Dunn. One.
Mr. Mole. So far.
Mr. Dunn. Busy investigator.
Mr. Mole. Well, I can tell you, she has a lot of great
ideas. But if you look also at some of the state programs, so
Colorado and California, they have supported a number of
clinical trials. And in fact, Colorado has a clinical trial
looking specifically at PTSD and they are funding a VA to do
that work.
So I believe this is beginning to expand in the direction
it needs to go so we get more knowledge, we get some more
experience to do the more comprehensive study that you have
proposed.
Mr. Dunn. Thank you. Also Dr. Franklin, you expressed
concern about the reporting time. I am now on H.R. 100. Are
there timelines that do make sense to you for the reporting on
the--this is the Veteran Over-medication Suicide Prevention
Act, 100.
Ms. Franklin. I don't think timeline is the issue. The
issue, and we spoke about this last night with regard to this
proposal, definitely in spirit, and intent, there is a need to
do this type of data and surveillance. The issue is when you
look at 20 veterans a day and their life by suicide and 14 not
touching the VHA health care system. The way the proposal is
laid out, it would call for VA to capture medication, issue,
and the like from potential deaths that happened outside of our
system, not only from veterans that might be accessing care
through our choice program, but veterans access care through
other entities as well. So if it--
Mr. Dunn. You are saying difficult, then, to get the data.
Is that what I understand you--
Ms. Franklin. For those veterans that don't receive health
care in our health care system.
Mr. Dunn. Right.
Ms. Franklin. If it were strictly VHA health care system
proposal, provide thus and such as written in the proposal with
those that get health care through our organization, it would
be a thumbs up.
Mr. Dunn. Okay, good. That is exactly what I wanted to
underscore. With the 30 seconds left, Ms. Ilem, you said that
DAV could support certain sections of H.R. 100, it is the same
bill the suicide is reporting. Is there--what part of it do you
oppose? What part do you favor?
Ms. Ilem. I think what Dr. Franklin has mentioned, we were
concerned about the types of data collection and then how--you
know, it might be misleading in terms of how that is
interpreted. But you know, certainly, looking at VA data and
what they have available, we want to see oversight, obviously,
of black box medications and prescribing practices. So I think
just making sure that VA's experts in this have looked at it
and feel that it is going to benefit.
Mr. Dunn. Thank you, very much. And I want to say, Madam
Chair, that it comes up again and again, and across all of the
Committees. We need to get this drug into a schedule 2 status.
It makes everything so much easier to do. Thank you. I yield
back.
Ms. Brownley. Excuse me. Mr. Lamb, 5 minutes.
Mr. Lamb. Thank you, Madam Chairwoman. Dr. Franklin, we
talked a little bit about whole health at last night's hearing
and you heard some of my comments about it today. And I
appreciate your suggestion on maybe even widening the scope of
our bill now or in the future. Could you go into a little bit
more detail about that, about the planned expansion from 18 to
36, and then also what you think we could learn from the wider
VHA experience, you know, if we looked beyond those 36 sites?
And as relevant to suicide prevention, of course, but just
really in any manner that is effective for veterans.
Ms. Franklin. Absolutely. I am pleased that we have Dr.
Gaudet here to talk about it. But I am also, too, happy to
engage as well.
Mr. Lamb. Either of you, fine. Yeah. Thank you.
Ms. Franklin. I will ask her to take the lead.
Dr. Gaudet. Yeah, thank you. It is an important question.
And the reason we were hoping to actually expand that report is
that we do have an intention to do a national deployment of
whole health. And I am sure you are aware, but other members
may not be, that whole health includes complimentary
integrative approaches, but is actually way broader than that.
It is really redesigning how health care works to start with
what matters to the veteran, to help them explore a sense of
meaning and purpose in their life. And that is primarily done
through trained peers.
So while we have the 18 flagship sites that are fully
funded to implement the entire whole health system 140 health
care systems are doing aspects of whole health. So we would
love the opportunity to report back to you on the national
deployment and where those strategies are, along with the next
36 sites.
Mr. Lamb. Great. Thank you very much. Can you talk a little
bit more about--they told me about this when I visited the D.C.
site, but I presume that the expansion that has happened beyond
those 18 sites, does it have to do with the trainings that VA
has made available for peer and other health coaches to then go
back? I mean, that was kind of the way they explained it to
me--
Dr. Gaudet. Right.
Mr. Lamb. --that there was a voluntary program where you
could come and learn some of the practices, even if your site
didn't--
Dr. Gaudet. Right. So there are three core elements in this
redesign of health care. Of course, clinical care is critical
and that is in place. The two newer elements are peer piece,
which is designed around empowering. And I honestly believe,
and as it relates to suicide prevention, that this is the most
powerful piece of this entire approach. Trained peers to work
with other peers around regaining a sense of meaning and
purpose in their life. Then from that point, and there are
peers trained at every facility now. So that is offered whether
they are a flagship site or what other aspects you are doing.
In addition to that, the real goal of the peer piece is
empowerment and engagement in your life. But now veterans need
support in new ways to approach their life. So the well-being
programs, which you described in D.C., places where veterans
can drop in, have experiences in yoga, or mindfulness, or
nutrition, or battlefield acupuncture, a whole myriad of self-
care strategies that empowers them is the second element.
So different facilities are doing different elements. The
18 are doing all of those three components and every facility
has trained peers.
Mr. Lamb. That is great. Thank you. Has VA already decided
what the new sites are going to be from the 18 to 36? Has that
been--
Dr. Gaudet. Yeah, we have--so each network has proposed two
sites, thus 36, and those haven't been announced yet, but we
have those 36 and that collaborative will start this summer.
Mr. Lamb. Okay. Excellent. Thank you. I will be hoping
beyond hope that one of Pittsburgh sites might be included, but
if not, we will certainly work hard to get our share of the--
Dr. Gaudet. Absolutely.
Mr. Lamb [continued]. --program underway. Maybe I could
become a peer something. You know what I mean.
Dr. Gaudet. That would be fabulous.
Mr. Lamb. Yeah. They tried to put one of the acupuncture
ear things on me when I was there at D.C. It didn't quite work
out, I don't think, but--
Dr. Gaudet. We can arrange for that.
Mr. Lamb. Yeah. I applaud your thinking and your expansion
efforts on this. You guys are ahead of the game, I think, and I
do think it is a big part of the future of health care more
generally, not just for veterans.
And I guess one last thought, if you have anything, Dr.
Franklin, on it is I also see a program like this as a way to
appeal to veterans who are not really using the VA system right
now because it just--I think it just matches a little bit more
about what younger people in particular think health care
should be like.
Do you think it is a way that we can find to reach these 13
veterans of the 20 everyday who are not coming to the VA for
services?
Ms. Franklin. Yes, absolutely. I have been in close
collaboration with Dr. Gaudet on this very issue, particularly
within the first 12 months of time when they leave active duty
service. We have a project together where we are working on
trying to help transitioning servicemembers, right when they
leave the DoD roll right into the whole health program and
start their VA experience that way.
Mr. Lamb. Thank you very much for your efforts. Madam
Chairwoman, I yield back.
Ms. Brownley. Thank you, Mr. Lamb. And Ms. Radewagen, you
have 5 minutes.
Ms. Radewagen. Thank you, Madam Chairwoman. I want to thank
the panel for appearing today. My question is for Dr. Franklin.
Ms. Franklin. Yes, ma'am.
Ms. Radewagen. In your testimony, you referenced the
development of a new suicide prevention coordinator program
guidebook and a suicide prevention program directive. When will
these be approved and released to the field?
Ms. Franklin. I don't have the exact dates with me, but I
can definitely get those back to the Committee in very short
order.
Ms. Radewagen. So in your opinion, is the suicide
prevention program and the coordinators who are responsible for
its execution, are they consistently trained and monitored
throughout the VA system?
Ms. Franklin. Yes, they are consistently trained and
monitored. They are trained through a number of different
portals and avenues that I can run through with you if you are
interested. And then there are a number of oversight processes
and protocols in place at the VISN level and at the VACO level
through a number of bodies.
Ms. Radewagen. Thank you.
Ms. Franklin. I am happy to get into more details with you.
I am also cognizant of the fact that you might have more
questions. So--
Ms. Radewagen. Yes.
Ms. Franklin. Okay.
Ms. Radewagen. So Dr. Franklin, I think a study such as the
one outlined in H.R. 2372 could be useful in helping to define
the prior scope of VA cooperation with non-profit and community
entities in its suicide prevention work. Do you have an
estimate as to how many such agreements currently exist and
give us an example of one or two and how they are working?
Ms. Franklin. Sure. Absolutely. So within my program in
suicide prevention, we have a total right now of 68 partners
and this is just my little program. This does not--little I
shouldn't say, but this does not count for the choice program
and all the partners in other entities across the VA. But we
have 68. Of those, 34 are signed MOAs or MOUs. And others are
just informal, and they agreed to partner with us, and we do
good work together, but we have not solidified it on pen and
paper.
And I will give you an example of one with Walgreens. So we
have an MOA with Walgreens recognizing--reference the 14
veterans that there may be some veterans that might pick up
their prescription at Walgreens. And they might touch a
Walgreens facility. So this MOA has--calls for us to train
Walgreens pharmacist on veteran culture, cultural competence,
what it means to where the uniform, and how to ask the
question, ``Have you served?'' And ``Have you worn the''--
``What is that like?'' And to really join with our veterans.
And then it teaches them also about suicide prevention risk.
So I actually train all of the pharmacists in Walgreens on
suicide prevention, myself. I get on a webinar, and I train
them, and I go through a series of Q and A with them to bring
them up to speed on everything from our veteran crisis line,
our campaign around be there, #be there for veterans, around
how to ask the question, ``Are you thinking of ending your
life?'' ``How many prescriptions are you on?''
And then Walgreens also takes our veteran crisis number and
pushes it out to all of their employees at the pharmacy. They
give it also to veterans and veterans' family members. And
those are just a few examples. But all of that is written into
stone on the official MOA and we stay true to it. It is not a
legally binding document, but it does go through legal review,
and we track the metrics according to it.
So for example, how many pharmacists have we trained? How
much engagement have we had with Walgreens? So that is one. We
also have an agreement with a non-profit called the
Independence Fund, which is a VSO that works with us on
reunions. And this is a brand new one, so I will give you sort
of the other side of the coin because Walgreens is sort of well
established.
The Independent Fund, recognizing the role of social
support in preventing veteran suicide and peer support has
partnered with the VA to reconstitute military units of
veterans to bring them back together for a reunion. And we
partner with them. The VA's role in that is to provide the
education, the psycho-educational content, classroom
instruction, and design the evaluation protocol.
They are in the pilot stage, so we have got to grow the
evidence on this. It is small pilots. We have had one so far.
The second one is coming up the first week of May where we will
continue to test this model of bringing units back together.
Ms. Brownley. You are running short on time.
Ms. Radewagen. Thank you. Thank you, Dr. Franklin.
Ms. Franklin. Yes, ma'am.
Ms. Radewagen. But looking ahead to the implementation of
the president's prevents executive order that would provide for
grants to communities to increase collaboration, how do you
envision these grantees coordinating with your other partners?
Ms. Franklin. Yes, this is an important thing that we have
been talking about in the building as well, so I appreciate the
question because there is a number of existing partners that
are going to be able to bring capabilities to the table. And so
we are planning on hosting a series of webinars and
informational instructions to share best practices across the
new and innovative community partners that will likely come to
the table from Prevents, with the existing infrastructure, in
such a way that we can leverage--force multipliers in that
equation.
Ms. Radewagen. Thank you so much. Madam Chair, I yield back
my--
Ms. Franklin. Thank you.
Ms. Radewagen [continued]. --time.
Ms. Brownley. Thank you, Ms. Radewagen. Now, we have Mr.
Cisneros for 5 minutes.
Mr. Cisneros. Thank you, Madam Chair. Thank you all for
being here today. First, I have got a question for the VSOs. I
am getting like an echo.
I heard repercussions for--you know, that was--somebody
said that veterans that are going, and they are afraid of
repercussions if they talk to the VA doctor about marijuana
use, or they have had repercussions for bringing it up to their
VA doctors. Can you give me an example of any veteran--what
type of repercussions have they had, you know, for bringing
that up to their doctor?
Ms. Mullen. Yeah, I will start. So I won't use names to
protect our IAVA members, but we have had several tell us that
they will talk to their VA clinician about their cannabis use,
and suddenly in their charts, it will say that they have a
substance use disorder. And once that happens, it means they
have to go through certain procedures to get their benefits
back, to get medications back, or in other instances, they will
be taken off certain medications because of their cannabis use,
where there is no interaction.
For example, perhaps they are on some sort of opioid for
chronic pain and they talk about using cannabis as another
factor that helps with that, and there is research to suggest
that using both in tandem actually does help that. And then all
of a sudden, that prescription is taken away from them. So that
is just two examples.
Mr. Cisneros. And Dr.--
Ms. Franklin. I also offer that I am happy to take it back
to the organization to double down on our efforts to educated
providers and nurses and physicians on this issue to make sure
that there are no repercussions. And if there are individual
case studies, I know Dr. Mole and I are happy to chase those
down and ensure that there are not ramifications or negative
consequences for veterans.
Mr. Cisneros. Well, that was my question, you know, to you,
is you said that patients are allowed to discuss this with
their doctors. But is there a VA policy in place, is there a
directive in place that says they are allowed to bring this and
there won't be any repercussions, or that they won't be listed
as a substance abuse? What are those policies? What is--
Mr. Mole. So the policy isn't as prescriptive as you won't
do A, B, C, D, E. But it says that you will not be denied
benefits. We encourage you to have a conversation. We encourage
the providers to document that so that other providers know and
are aware. And to use that information as part of the treatment
plan, and how you develop what is appropriate for that
individual veteran. That is what we ask for the providers to
do.
And I second what you are saying is we want to take a look
at providers who are deviating from that policy. Absolutely.
Ms. Franklin. Double down on this.
Mr. Cisneros. Yeah. No, I would appreciate that. And
Representative Steube, his bill right now that I am happy to
co-sponsor with him, I think has done a great deal that will go
and make sure that these veterans don't have to face
repercussions and that they can feel comfortable talking about
their plans with their doctors. And I am glad that he brought
forth that legislation. I am glad he came up to me and asked me
to be a co-sponsor of that.
Just another question going in a different direction, as
far as the study that you said the VA wasn't in support of H.R.
712. Now, you had mentioned that one of the reasons was that
there should be a smaller study first. But you know, this is a
crisis situation. A lot of these veterans are using this to--
because of chronic pain to deal with PTSD. You know, why not do
the big study first, to go out there and to do this to kind of
find the problem and do the research that needs to be done so
that we can get to that point to where hopefully the VA can one
day can start prescribing cannabis to help treat these
conditions that our veterans are dealing with.
Ms. Franklin. Yeah, there are a number of study protocols
when you are designing a research study and just a number of
processes and reviews when you are looking for evidence and
typically you have got to be safe, and do no harm, and start
small, and grow evidence over time. But certainly we can work
with the best academics in this space and make sure that we are
designing it at the right size that both gets after the
evidence that you are after and protects human subjects at the
same time, without a doubt.
Mr. Cisneros. Yeah, no. Like I said, I think we are in a
situation right now where we can't be taking baby steps. We
have got to start running to get there. And if it takes a
bigger study to help us do that, then that is what we need to
do. So I am also very supportive of H.R. 712. But I yield back
my time. I just want to thank you very much for being here
today. Thank you.
Ms. Brownley. Thank you, Mr. Cisneros. Next is Mr. Steube.
Mr. Steube. Thank you, Madam Chair. First, I just want to
thank you for bringing up H.R. 2191, Veterans Cannabis Use for
Safe Healing Act. I represent Florida and Florida recently has
gone through a medicinal marijuana ballot initiative. There
was--I was actually involved in the state legislature where
there was legislation and then it became a ballot initiative.
And I will say, Dr. Franklin, you had stated that the VA is not
denying benefits to veterans. That is not what I am hearing
from people in Florida.
Just Google my district and I just went on a local
newspaper and there is like 10 different articles, interviews
on local stations. So at the very least, I think there is an
incredible amount of confusion as to whether veterans who have
gotten a--the way it works in Florida is you have to get a
prescription by two independent physicians to then get
medicinal cannabis. And I think there is definitely some
confusion, and I have heard from veterans directly who have
said they have been denied benefits from the VA because they
have tested positive for marijuana and THC.
So I think--that is why I did the bill, because at least in
Florida, I have seen some real challenges in Florida as the
application of state medicinal cannabis bills and veterans who
are using VA benefits. So I think it is important that the law
is clear. You said that there is a directive. The
Administrative Directive 1315, but isn't it true if a new
administration came along, or a new secretary came along, can't
a directive change or be cancelled out?
Ms. Franklin. Typically, at the bottom of the directive,
they will have a statement that says something like, and this
is generally. I haven't looked at this exact one. But it will
say, ``This remains in effect until,'' and it will have a date
and time, or it will say, ``Upon the change of leadership, this
must be updated.'' So without seeing it, although it sounds--it
looks like maybe Dr. Mole might have a copy of it, but I hear
your underlying message, which is confusion and need to do
proper education and outreach to veterans and communities
across the Nation on what the parameters are and making sure
folks know about this policy and that it is not taken in a
negative way for veterans.
Mr. Steube. Well, but you guys are stating that you are
against the bill that we are working on that would codify this.
And that is my question in saying can't directives change? I
mean, if a new secretary comes in and changes this specific
directive that allows veterans to utilize medicinal cannabis,
if we have a law in place that says legally under the 10th
amendment to the Constitution and the Federal government has
recognized that if states have legalize medicinal cannabis,
that the VA shall not deny veterans benefits. I think that
would go a long way to assuring that there isn't confusion
within states that have authorized medicinal cannabis.
So I understand from the DEA perspective why you are
against part of the bill, but you have a directive that
basically states what we are trying to make law. And so that it
is not confusion to people in states that have legalized it.
So I mean, I would be happy to work with the VA on this
issue. I am very passionate about this issue because it is a
big issue for Floridians. I didn't even vote for the ballot
initiative that passed, but it has passed. And I believe under
the 10th amendment of the Constitution, that is the law in
Florida and veterans should not be denied benefits that they
are due and owed for their service to our country just because
they now have a prescription for medicinal cannabis.
I think it needs to be very, very clear that that is not
going to happen to them.
Mr. Mole. Yeah. And I think we will take this back. And we
are happy to work with you and others on that language.
Mr. Steube. And if there is other--you had mentioned
several things on that specific bill that I am working on that
you have issues with, but I am happy to work with you moving
forward. I think this is--it is certainly an important issue to
a state like Florida that has--and it is new in Florida. This
has only been around a couple of years. So they are going kind
of through their legal growing pains as well. But I think it is
important that our veteran community in states that have
authorized it, those veterans know that they are not going to--
and if you Google what I told you to Google and you watch some
of the interviews, veterans are actually afraid to go to the VA
to use services that they are accredited to do because if they
test positive for THC or marijuana, they are afraid that they
are going to lose their benefits.
So it is certainly--like there definitely needs to be some
messaging to the veterans in states like Florida that you are
not going to lose your benefits if you legally are using a
state sanctioned medicinal cannabis act. So thank you. And that
is--I would be happy to work with you on that.
Ms. Franklin. Appreciate it.
Mr. Steube. I will yield back the balance of my time.
Ms. Brownley. Thank you, Mr. Steube. Mr. Rose, 5 minutes.
Mr. Rose. Thank you, Madam Chairwoman. I just wanted to
address something quickly with the VA to clear up some
confusion. We have heard concerns regarding potential HIPAA
violations in regards to the bill. I, along with several others
on this Committee, are introducing FIGHT Veteran Suicide Act,
requiring the VA to notify Congress of certain information
regarding veterans that died by suicide on VA campuses.
Particularly, it asked for the enrollment status of the veteran
with respect to the patient enrollment system of the
department.
The most recent encounter between the veteran and the--of
Veterans Health Administration whether the veteran had private
medical insurance, the armed force, and time period in which
the veteran served, the age, employment, marital status,
housing status to the veteran, and confirmation to the
secretary of Veterans Affairs has provided notice to the
immediate family members.
To your knowledge, does the requested notification require
the release of any protected health information and is thus
subject to HIPAA protection?
Ms. Franklin. I would need to put that through a full HIPAA
review with our attorneys. I don't have the law memorized and I
am not sure. But I will tell you that one of the things that is
concerning that we are trying to balance, although you heard in
my testimony that we absolutely approve--we recommend and we
give this a thumb's up in terms of full support for this report
to Congress, is just making sure that we are careful around
notifying people in general about suicides that occur in
districts, perhaps, where there is just a very small number.
And if that got released out to the media in a way that were
reported and a mother, or grandmother, or wife of a veteran
that ended his or her life by suicide saw that swirl out in the
media in a negative way that impacted their family.
So it is just a matter of observing the dignity there. But
in terms of HIPAA, we can run it through the HIPAA legal review
and tell you what the outcome is.
Mr. Rose. But you are not seeing any glaring red flags
right now? Or else--I mean, the VA just endorsed the bill. You
would--
Ms. Franklin. So likely the attorneys looked at the--
Mr. Rose. Sure.
Ms. Franklin. Looking at it from a social science
perspective, I don't.
Mr. Rose. Okay. All right. No, that is very helpful. I
have--I just wanted to really ask you all a quick question.
Speaking to the VA folks last night, raised certain facts and
figures that show that multiple deployments that are packed
together with minimum dwell time, as well as minimum training
time prior to an initial deployment, then a second deployment,
do substantially increase the risk of suicide. Have you seen
these stats bear out amongst your membership?
Ms. Mullen. The short answer is absolutely. You can see
from our members that 75 percent have served in Iraq, 39
percent have served in Afghanistan. Quick math shows you that
is more than 100 percent. And we know--we ask about deployments
as well. And most do at least one OIF and at least one OEF.
Mr. Rose. Sure.
Ms. Mullen. So we deal with a population that has multiple
deployments, most of which are while they are doing Guard or
Reserve duty, which was another topic of conversation and
something that IAVA is concerned about, especially when we are
talking about the suicide rates when it comes to Guard and
Reservists.
Mr. Rose. No, absolutely. No, look, as a Guardsman
presently, as a vet who has too many friends who deployed five,
six, seven times, I think it is our responsibility as well to
make recommendations to the DoD as to what is responsible and
what is not. And so we are here today considering veterans'
suicide. We are here today considering overall veterans'
health; all present servicemembers are future veterans.
So what, if any, specifically, recommendations would you
make to the DoD, as you are concerned about Iraq and
Afghanistan veterans as to dwell time, as to op tempo, as to
minimum training prior to deployment?
Ms. Mullen. That is a great question. When it comes to
specific timelines, IAVA does not have specific recommendations
to that, but we do hold very high the health and well-being of
servicemembers and their families. Coming into that is not only
the health of the servicemember, but the experiences
transitioning back from deployments, moves within military
families, how many moves they are doing, the impact on their
children and wives, spouses, husbands, whatever it may be.
So of upmost concern, but I don't have specific
recommendations for the--
Mr. Rose. And do you think in your estimation the VA should
be in the business of making recommendations to the DoD about
op tempo and dwell time?
Ms. Mullen. I would say I don't have the background to make
that recommendation. I know that VA is doing a lot to support
transitioning servicemembers, especially in their last 18
months and as they transition out. I think that is a key
timeframe where VA should be engaging with servicemembers as
they are going through the TAP program, and ensuring that they
are making a smooth transition. Especially because we know that
is a height in time for suicidality among that age group and
among that transition service--
Mr. Rose. Yeah. And look, I am just going to close out with
this, though. The message I got from the VA yesterday, and we
all did, was that there are certain things out of their
control. There are certain things out of their control, one of
which is op tempo, one of which is the intensity of modern-day
combat.
And what I still do not yet understand if there are certain
things out of the VA's control, why would the VA then not make
recommendations to the entity unto which that is under their
purview?
Ms. Franklin. Look, I will share with you that I worked for
the DoD and have only come over to the VA in the last year. And
we can and will make recommendations to everybody and anybody
in this enterprise when it comes to saving lives. And so
whether or not DoD will embrace those recommendations is likely
to be determined. But when you are talking about dwell time,
there is not only the issue of multiple deployments, but it is
also the issue of length of deployment. And so--
Mr. Rose. Totally agree.
Ms. Franklin [continued]. --there are some studies that
show that troops can deploy out 3 months, 7 or 8 times and be
fine, and then there are other studies that show they will
deploy out 1 time for 18 months, and that particular type of
combat and/or deployment will crush them for months to come.
And particularly when it applies to coming in and out of
roles with regard to being a spouse and a parent. And so all of
that is quite complicated. And to the extent that that has been
studied or can be looked at longitudinally, and we can give
those recommendations to the DA--the DoD, I am sorry, we can
and will.
Mr. Rose. So, you know, as I think of my friends who have
done 15-month deployments, and I never did, but that is two
Christmases, two birthdays, two anniversaries.
Ms. Franklin. Yes, sir. Yes, sir. I--
Mr. Rose. You know, you deploy when your kid is 6 months
old for 15 months, you come back and your child doesn't
recognize you, doesn't know who you are.
Ms. Franklin. Yes.
Mr. Rose. So what I am hearing is that you are now--the VA
is comfortable making recommendations to the DoD as to what is
acceptable or non-risky op tempo, and what are the types of op
tempos and the lengths of deployments that do present
potentially undue risk for future suicide?
Ms. Franklin. We will tell them what we are learning about
suicide, up, down, and all around. What we won't do is get into
the business of war fighting with them.
Mr. Rose. Of course. And no one--
Ms. Franklin. Very well.
Mr. Rose. I mean, I understand that. I wouldn't want you in
that business.
Ms. Franklin. Yes.
Mr. Rose. But I do want you--
Ms. Brownley. Mr. Rose, your line of questioning is very
good, but your time has--
Mr. Rose. Understood. Thank you.
Ms. Brownley. Yes.
Ms. Franklin. Thank you.
Mr. Barr. Thank you, Madam Chairwoman, and I agree, great
line of questioning there. So I was enjoying listening to the
dialogue.
Let me shift gears, Dr. Franklin and Dr. Gaudet. Earlier
this year, Dr. Stone with the VA--stated that the VA had 60
active equine programs across the VA system and concurred that
they are very effective in benefitting veterans.
Last night, we heard from the National Institute of Mental
Health, similarly that equine assisted therapy programs have
some benefits in terms of mindfulness and other benefits,
especially for returning veterans who are struggling with post-
traumatic stress and other issues.
I was very encouraged by Dr. Stone's statement that the VA
is actively looking to expand equine assisted therapy, as well
as all of the VA's adaptive sports programs. Is equine assisted
therapy included in the services offered through the VA's whole
health initiative?
Dr. Gaudet. I can probably take that. Thank you. The
concept of the whole health initiative is a broad umbrella. So
while technically that doesn't fall under my office really
doesn't matter for this conversation. What matters is that the
concept of supporting people's health and well-being and
resilience through any means that is of effect and benefit for
that veteran is a part of that approach.
Mr. Barr. Well, this is Kentucky Derby week and horses are
on my mind as a Kentuckian.
Dr. Gaudet. Yes, of course.
Mr. Barr. But I can tell you on a more serious note that
throughout the calendar year, I have witnessed some really
transformational things, positive things happened with veteran
constituents of mine who have the benefit of access to equine
assisted therapy that may not exist in places outside of
Kentucky, for example, and I encourage you to look at that.
In legislation offered by my colleague, Mr. Lamb, there is
a provision that allows the VA to report on the accessibility
and availability of any other service the secretary determines
appropriate. If passed, Dr. Franklin, would you be willing to
include equine assisted therapy as part of this report?
Ms. Franklin. Yes, sir.
Mr. Barr. Thank you. Let me shift gears to some of the
cannabis related legislation on the docket here today. Back to
you, Dr. Franklin and Dr. Gaudet. As you may know, the 2008
Pharm Bill took steps to deschedule industrial hemp derived CBD
products. And a lot of people don't fully appreciate the
distinction that was made in the Pharm bill related to low THC
CBD cannabis versus the high THC marijuana that remains
prohibited under Federal law.
Given the passage of this legislation, has the VA, given
some concerns about the existing marijuana legislation on the
docket today, has the VA changed their approach into
researching CBD--low THC CBD treatments for veterans?
Ms. Franklin. I will defer to Dr. Mole.
Mr. Mole. I am not sure if that bill would have shifted
people, but I think clearly investigators are interested in CBD
oils. They are interested in low THC or no THC if that is
possible. So I know that work is ongoing and there is
investigators interested in working on those types of products.
The Pharm bill, I was having to run through some papers
because we had some struggles with how to interpret the Pharm
bill versus a schedule one substance. And so--
Mr. Barr. Well, if I could, to the extent the VA has
concerns about the psychoactive impact and some of the studies
relating to schizophrenia with marijuana, let me assure you
that hemp with low THC doesn't present those potential risks,
whereas CBD, which is now legal under Federal law, may present
an opportunity for the VA to take those incremental steps that
you all were talking about in your testimony before. And the
Pharm bill, just for informational purposes does authorize the
FDA and USDA to complete regulations. Those are ongoing. And
once that is completed, I would encourage the VA to look at CBD
as an initial step on this road to cannabis as a potential
medicinal opportunity.
Mr. Mole. So just very quickly, I don't want to use your
time. So what Dr. Franklin said earlier in the testimony was
that our current study under way in San Diego is using CBD.
Mr. Barr. Okay. Great. Thank you very much. And finally
just to the VSOs, Ms. Mullen, Mr. Fuentes, and Ms. Ilem, have
you all had an opportunity to play a role in suicide prevention
to the extent that I know your organizations can we--we know
from the testimony last night that there are too many veterans
who are committing suicide are not accessing, at least
recently, the VHA system.
Are you all--do you feel like you all are able to reach
those veterans?
Ms. Ilem. I would say for DAV, we just did--recently did
a--had VA come over and do a save program with us, training,
making sure that our headquarters staff understands how
everybody can participate in suicide prevention.
And then we also included that now in our training for our
national service officers, who are located throughout the
country and see veterans every day, assisting them with their
claims. So we know and subscribe to VA's premise that suicide
is everyone's business. We all have to play our part. We have
to include this information in our magazines, our brochures, we
have to talk to veterans, make sure that we are all taking care
to watch out for each other.
So I think, you know, we are doing what we can as an
organization to spread that.
Mr. Fuentes. Same thing for the VFW. We have one of those
unofficial MOUs with VA. Part of our mental wellness campaign
to essentially help veterans, and their caregivers and family
members, the community identify the five signs. Emotional
distress is a partnership with given our Elizabeth Dole
Foundation and Walgreens as well to bring people into our 6,500
posts around the world, and train them, part of the day--so we
are going it. We are going to continue doing. And VA is being a
good partner.
Ms. Mullen. Yeah, from IAVA's perspective, we operate a bit
differently than the legacy VSOs over here and we build online
communities to engage our members in suicide prevention and
mental health care. And we do that effectively and efficiently.
I will also say that our rapid response referral program
has an MOU with the VA as well. They are master's level social
workers that work one on one with veterans to do warm hand-
offs. So when a veteran calls our rapid response referral
program in crisis, they are able to connect them to the VCL
immediately. Last year we had over 100 saves through that
program.
So it is an amazing program. We also have about 25 percent
of our members that don't access VA health care. They do
private health insurance only. So I can tell you that the VA
members, the IAVA members are definitely outside the VA program
and we are connecting with them with suicide prevention and
mental health care.
Mr. Barr. Thank you. I yield back.
Ms. Brownley. Thank you, Mr. Barr. And last but not least,
Mr. Brindisi.
Mr. Brindisi. Thank you, Madam Chair. Sorry for being late.
Juggling a couple different Committees today, but thank you for
allowing me to be here and giving me an opportunity to ask a
few questions about our bill, H.R. 233, the Support of Suicide
Prevention Coordinators Act.
And I just want to ask just a couple brief questions
because I think that coordinators are really the face of the
VA's efforts to address the veteran's suicide epidemic and many
report being overworked or unable to keep up with some of their
responsibilities.
So essentially what this act would do is give our
prevention coordinators the resources they need to be able to
do an effective job. And specifically, the bill would require
the comptroller general to conduct an assessment of the
responsibilities, workload, and vacancy rates of the Department
of Veterans Affairs suicide prevention coordinators and submit
it to Congress within one year.
So I know that the VA hasn't taken an official position on
the bill, but I assume that you would welcome an outside
assessment by the comptroller general to conduct an assessment
and report back to Congress.
Ms. Franklin. Yes. And I also shared with the Committee
earlier that we have an assessment well underway where we are
looking not only at just the role of the suicide prevention
coordinators, but more broadly in the role of other
capabilities that we might need to bring to the table. As part
of our new strategy, we are trying to work with veterans and
get after suicide where they work, live, and thrive, which is
outside of our four walls.
The role of the SPCs has largely been focused on clinical
work with very limited outreach events, five a month. And so we
are not only looking at their role, but we have a study
underway and an analysis where we are looking at other
capabilities as well that might need to get brought to the
table.
Mr. Brindisi. Can you talk a little bit about, because I
represent a very rural district, some of the outreach efforts
that are being done in more rural areas where you may not be
close to a CBOC or a hospital, and where public transportation
options are pretty poor; how do you conduct outreach in those
areas?
Ms. Franklin. Yeah, it is a difficult issue, just as you
describe. And we try to tackle it through a multi-pronged
approach, whether that is our SPCs, which that alone would not
solve it because as you describe, it is rural, and they have to
go long and far to get across the span. Using online technology
helps, but again alone will not solve it because not all of
these areas have broadband and the width to do it. And then we
have our mobile vet centers that will go out. I don't know if
you have ever interacted with his capability, but it is
actually like a vet center on wheels, if you will, and they
will go out to rural areas. We are trying to target when and
where to place them.
And we have a movement underway that allows for that to
happen. So that is the third. And then the fourth is we are
using partners. And so while we may not be able to outreach and
get after this issue with every single person ourselves, we are
trying to have our partners help serve as force multipliers and
help us with this outreach as well. So when there are local
entities and community-based folks, that--people that live in
rural America know well and trust well, and they are equipped
with the signs and symptoms of risk, and they can carry VA's
message and help us in a coordinated fashion. I think that adds
to it.
But it is a difficult phenomenon that we have to continue
to work on in rural America.
Mr. Brindisi. Okay. Well, I am always willing to work with
you guys on that, representing a very large rural district. And
we know that access to health care is very hard to come by,
especially for our veterans in those communities. So any
initiatives that you would like to partner on, I am always
willing to work on that.
Just one last question. I know in your testimony, it says
that the VA's mental health hiring initiative is active and is
addressing current hiring plans. What is the timeline? And I
know that also it said that the suicide prevention coordinator
program guidebook and suicide prevention program directive are
currently in development; what is the timeline on those
initiatives?
Ms. Franklin. Yes. For the mental health hiring initiative,
we had a goal of June 2019 to hire over 1,000 mental health
providers and we have exceeded that goal. I believe it is at
1,065. We still--we do still have some shortcomings in the area
of suicide prevention--coordinators, I am sorry.
Mr. Brindisi. Yeah.
Ms. Franklin. We did an analysis of that job bucket and we
determined that we needed an additional 386, of which we have
hired a good number and we have 244 remaining of that analysis
in order to get even with that--with the Board with that
community. So June '19 to answer your specific question on the
date.
I do not have the timeline for the directive and the
suicide prevention guidebook, which will really be the force
function for working with the suicide prevention coordinators
on how to do their day to day jobs, an increased layer of
accountability, if you will, from the VACO office and the local
SPC. But I committed to one of the Congresswomen earlier this
morning that I would bring those dates. And as soon as I get
back to the office, I will pull it. I just hesitate to give one
that might be off.
Mr. Brindisi. Absolutely. If you could share that with us
down the road--
Ms. Franklin. Will do.
Mr. Brindisi [continued]. --we would certainly appreciate
that.
Ms. Franklin. Yes.
Mr. Brindisi. I yield back my time.
Ms. Brownley. Thank you very much. And I think that ends
our hearing, but before closing, I wanted to make a couple of
points and really just two. And one is around the topic of
suicide prevention and we have several bills here today that
address suicide prevention and I just encourage the VA, the
VSOs, the author of the bills to try to work together to make
these bills work because I think their intention, and I think
most everybody agrees that their intention is good and making
sure that we can succeed in that.
And I think, obviously, with suicide prevention, we still
have a lot more to do. And last night's hearing was good. This
one has been good. And I am sure we will have more hearings on
it.
And the second piece is around the cannabis piece too, and
trying to make that work. And I will say I have heard from my
constituents and my veterans as well this issue of fear of
testing positively and being worried that their benefits will
be taken away from them. And I remember a couple of years ago,
we had a family come in to testify whose son had committed
suicide. And he committed suicide and he left a suicide note.
And he basically said he was trapped in his body, that he had
been so medicated and trapped in his body that just life wasn't
worth living anymore.
And so I do think this cannabis issue and proceeding with
it, and this relationship to suicide prevention, there is a
nexus here, and I think we just have to really be committed to
the cannabis issue and to the suicide issue, but where this
nexus is. And so those are the two points and my two take-aways
from the Committee. And again, I just wanted to reiterate this
Committee hearing. The Members and witnesses went over a little
bit in their time, which I allowed. I want to keep the
conversation as free flowing as I possibly can.
Other hearings, I might have to call it, this one, we
seemed to have the time to be able to do it. So I think it was
a good hearing and again I thank the witnesses for being here.
And Mr. Barr, if you have any closing comments, the time is
yours.
Mr. Barr. Just again, thank you to our witnesses. Thank you
for your service for addressing these very important issues. We
have got to get this veteran suicide issued under control.
Twenty a day is unconscionable, it is intolerable, and I
appreciate everyone here, both on this side of the desk and
also at the table for working with us to tackle this very
important problem. And Madam Chairwoman, thank you for your
commitment to that issue as well. I yield back.
Ms. Brownley. Thank you, Mr. Barr. And with that, all
Members will have 5 legislative days to revise and extend their
remarks and include extraneous materials. And without
objection, this Subcommittee stands adjourned. Thank you.
[Whereupon, at 11:49 a.m., the Subcommittee was adjourned.]
A P P E N D I X
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Prepared Statement of Congressman J. Luis Correa (CA-46)
Chairwoman Brownley and Ranking Member Dunn, thank you for the
invitation to appear before you today. I appreciate the opportunity to
testify about my bipartisan legislation, H.R. 712, the ``VA Medicinal
Cannabis Research Act.''
As you know, veterans experience physical and psychological
injuries at higher rates than their civilian counterparts as a result
of their military service to our country. Unfortunately, the current
clinical treatment of prescription opioids to address post-traumatic
stress disorder (PTSD) and chronic pain have at times been ineffective
or at worst had dangerous results such as addiction or death. In
response to the opioids crisis, Congress, the VA, and veterans service
organizations nationwide correctly focused their attention on reducing
opioids addiction and overdoses. As twenty veterans tragically die from
suicide each day, we, as policymakers, should consider alternatives to
the treatment of PTSD and chronic pain.
One alternative treatment that has been discussed by veterans that
I have met in my congressional district and cited by nationwide surveys
commissioned by the American Legion and Iraq and Afghanistan Veterans
of America (I-A-V-A) is the therapeutic benefits of medical cannabis to
manage chronic pain and other health ailments. According to the Legion,
92 percent of veteran households surveyed supported medical cannabis
research while an estimated twenty-two percent of veterans reported the
use of medical cannabis to treat a mental or physical condition.
Similarly, the I-A-V-A survey demonstrated that over 80 percent of
their membership supported the legalization of medical cannabis.
Therefore, with my colleague and friend Congressman Clay Higgins, I
introduced the bipartisan VA Medicinal Cannabis Research Act to promote
understanding of the safety and effectiveness of medical cannabis use
by veterans diagnosed with post-traumatic stress disorder (PTSD) and
chronic pain. This bill requires VA to conduct a double-blind clinical
trial on the impact of different forms and delivery methods of cannabis
on specific health conditions of eligible veterans with PTSD and
chronic pain.
With twenty-two percent of veterans currently using cannabis for
medicinal purposes, it is important that doctors be able to fully
advise veterans on the potential impacts and benefits of medical
cannabis use on post-traumatic stress disorder (PTSD) and chronic pain.
Research into medical cannabis is necessary and supported by the
veteran community.
I want to thank Disabled American Veterans, Veterans of Foreign
Wars, Iraq and Afghanistan Veterans of America, and the many other
veterans and medical groups for their support of the bill.
Thank you again for inviting me to testify about H.R. 712, the VA
Medicinal Cannabis Research Act. This legislation is a pragmatic and
sensible approach for research on medical cannabis that will hopefully
result in safe, alternative treatments for our veterans and reduce the
number of veterans suicides.
We owe this to our veterans who were willing to make the ultimate
sacrifice for our Nation's freedom. I look forward to working with you
all to move this bill forward and am happy to answer any questions you
may have.
Prepared Statement of Conor Lamb Vice Chair, HVAC
Whole Veteran Testimony:
Madam Chairwoman, I know you and everyone in this room shares my
deep concern regarding the high rate of veteran suicide across the
country.
It is essential that we make all necessary tools available to
veterans as they face their individual mental health challenges.
Instead of concentrating on an isolated condition, Whole Health
programs and treatments focus on the whole veteran.
Physical, emotional, and mental health are all interconnected, and
the VA has the important responsibility of supporting veterans in
achieving their highest overall well-being.
VA's Whole Health Program is integral to VA's suicide prevention
efforts, yet these services are not available at every facility leaving
many veterans wanting.
The Whole Veteran Act requires the VA to provide Congress with
information regarding the accessibility and availability of components
of Whole Health programs.
By identifying the current gaps in availability, the VA can take
the adequate steps to improve the mental health and well-being of all
our veterans no matter where they live.
Thank you and I yield back.
Prepared Statement of Dr. Keita Franklin
Good morning, Chairwoman Brownley, Ranking Member Dunn, and Members
of the Subcommittee. Thank you for inviting us here today to present
our views on several bills that would affect VA health programs and
services. With me today are Dr. Tracy Gaudet, Director, Office of
Patient Centered Care, Veterans Health Administration, and Dr. Larry
Mole, Chief Consultant, Population Health, Veterans Health
Administration.
We are providing views on H.R. 100, H.R. 712, H.R. 1647, H.R. 2191,
and four draft bills relating to Suicide Prevention and Mental Health
Memoranda between VA and non-VA entities, VA Suicide Prevention
Coordinators, Congressional notifications of Veteran suicides and
attempts, and a report on VA's Whole Health Transformation.
H.R. 100 - Veteran Overmedication and Suicide Prevention Act of 2019
H.R. 100 would direct VA to seek to enter into an agreement with
the National Academies of Sciences, Engineering, and Medicine (NASEM)
to conduct an independent review of the deaths by suicide of certain
covered Veterans during the previous 5 years, regardless of whether
such deaths have been reported by the Centers for Disease Control and
Prevention (CDC).
The review would include the following:
a description of and the total number of Veterans who
died by suicide, violent death, and accidental death;
a comprehensive list of prescribed medications and legal
and illegal substances as annotated on toxicology reports of these
Veterans;
a summary of medical diagnoses by agency physicians or
through programs of the agency that led to the prescribing of
medications in the comprehensive list in cases of posttraumatic stress
disorder (PTSD), traumatic brain injury, military sexual trauma, and
other anxiety and depressive disorders;
the number of instances in which one of these Veterans
was concurrently on multiple medications to treat these disorders;
the number of these Veterans who were not taking any
medication prescribed by VA or through a VA program;
the percentage of these Veterans who received a non-
medication first-line treatment compared to the percentage who received
medication only;
the number of instances in which a non-medication first-
line treatment was attempted and determined ineffective, which then led
to prescribing a medication;
a description and example of how VA determines and
updates the clinical guidelines governing medication prescribing;
an analysis of VA's use of pain scores during clinical
encounters and an evaluation of the relationship between the use of
such measurements and the number of Veterans on multiple medications;
a description of VA efforts to maintain mental health
professional staffing levels;
the percentage of Veterans with combat experience or
trauma related to combat;
identification of VA medical facilities with markedly
high prescription rates and suicide rates;
an analysis of collaboration by VA programs with state
Medicaid agencies and the Centers for Medicare and Medicaid Services;
an analysis of the collaboration between VA medical
centers (VAMC) with medical examiners' offices or local jurisdictions
to determine Veteran mortality and cause of death;
an identification and determination of a best practice
model to collect and share death certificate data;
a description of how data relating to death certificates
of Veterans is collected, determined, and reported by VA;
an assessment of any apparent patterns; and
recommendations for further action to improve the safety
and well-being of Veterans.
Not later than 180 days after entering into the agreement, NASEM
will complete its review and provide a report to the Secretary
containing the results of the review. Not later than 30 days after
completion of NASEM's review, the Secretary will submit to the
Committees on Veterans' Affairs of the House of Representatives and
Senate a report on the results of the review, which will also be
publicly available.
VA does not support this proposed legislation. This bill would be
redundant because of the current work occurring with NASEM. The Joint
Explanatory Statement for the Consolidated Appropriations Act of 2018
stated that VA's appropriations included $500,000 for NASEM to assess
the potential overmedication of Veterans during Fiscal Years (FY) 2010
to 2017 that led to suicides, deaths, mental disorders, and combat-
related traumas. This protocol can be easily augmented to examine
additional psychotropic medications as needed before the study is
funded for implementation without additional legislation. In addition,
hiring and workforce management for mental health professionals is
currently ongoing and being tracked and is easily reportable without
legislative action.
Section 2(a)(1) would require that NASEM use data that would likely
provide misleading results. VA becomes aware of most suicide deaths
through data obtained from the National Death Index established by
CDC's National Center for Health Statistics. However, these data are
available only after a delay, so the most recent information on
individuals dying from suicide would not be available within the bill's
required timeframe. CDC data provides the most comprehensive source for
determining Veterans' causes of death; utilizing other sources would
result in incomplete identification of covered Veterans who died from
suicide. Therefore, requesting a review of deaths by suicide regardless
of whether these deaths have been reported to CDC, as required by
section 2(a)(1), could lead to inaccurate or misleading data results.
Much of the data required to be collected under section 2(a)(2)
would be difficult to obtain and accurately interpret. Physicians are
not the only providers who prescribe medications, toxicology reports
may not always be done following death by suicide, and obtaining
complete and accurate information about what is (or is not) taken by
the patient outside VA would be challenging.
Section 2(a)(3) discusses the compilation of data, and to the
extent that any of these data could be re-identified to a specific
Veteran, then an analysis of the Health Insurance Portability and
Accountability Act (HIPAA) Privacy Act and any other applicable laws or
regulations meant to protect personal health information would be
required.
Finally, the deadline for completion and review of the report in
section 2(a)(4) is unrealistic. It does not seem possible to provide
the sheer volume of data the bill demands and have NASEM analyze it
within 180 days, particularly given that probably hundreds of different
offices at the local and state levels would have to be contacted to
provide certain information. Requiring VA's response within 30 days of
NASEM's findings could also limit our ability to thoughtfully and
carefully review the evidence they present, which could limit the
utility of this information.
H.R. 712 - VA Medical Cannabis Research Act 2019
H.R. 712 would require VA conduct a clinical trial of a size and
scope to include multiple strains of cannabis and multiple routes of
administration and to collect, analyze, and report data on covered
Veterans with multiple medical diagnoses and a multitude of clinical
outcome measures.
VA has a rich history of scientifically driven contributions that
have advanced health care through planning and implementing high
quality clinical trials so that we can all better understand the
results and potential for changing clinical practice when trials are
complete. VA's Office of Research and Development has a program in
place to fund clinical trials that are submitted to our expert peer
review system for evaluation of scientific merit based upon the
rationale, design, and feasibility of a proposal. Such trials could
include the topic of medical uses of cannabis for conditions that
impact Veterans. Clinical trial applications must detail the underlying
rationale for the use of an experimental intervention such as cannabis
for use in humans.
The proposed legislation with the mandated requirements is not
consistent with the practice of scientific design for randomized
clinical trials nor is it possible to conduct a single trial to obtain
the information desired. The specification in the legislation of the
multiple requirements such as type and content, administration route,
diagnostic specifications representing potential inclusion and
exclusion criteria, and outcome measures are not consistent with the
current state of scientific evidence, which suggests that smaller,
early phase controlled clinical trials with a focused set of specific
aims are warranted to determine initial proof of concept for medical
marijuana for a specific condition. Any trial with human subjects must
include evaluation of risks and benefits/safety and include the
smallest number of participants needed to avoid putting subjects at
risk unnecessarily. In any study, the size of the experimental
population is determined statistically so that the power or ability to
detect group differences (between control and experimental groups) is
based on known effects that can be shown using a specific outcome
measure. For a cannabis trial, some of these effects are not known,
thus a circumscribed approach to determine dose, administration
modality, and best outcome measure(s) must still be studied or shown in
a proof of concept approach to ensure the research would have the
ability to detect the impact of the intervention in a controlled way.
Typically, smaller early phase trial designs, instead of the extremely
large study suggested in legislation, would be used to advance our
knowledge of benefits and risks regarding cannabis before moving to the
type of more expansive approach described in this proposed legislation,
which is more akin to a program of research than a single clinical
trial. The requirements to simultaneously address different modes of
administration, different compositions, and different medical diagnoses
without consideration of underlying rationale and mechanisms would not
be a good use of taxpayer money, and in fact would not engender a
favorable scientific peer review evaluation or regulatory approval. A
plan forward to determine the legislative mandate should start with a
scientific query or review of what is known for diagnostic categories
of interest and what is logically called for in exploring next level
clinical investigation.
VA is actively encouraging a logical pathway to contribute to the
overall understanding of the possible contribution of cannabis and
derivative compounds and products to Veterans' health care. VA is
reviewing the current clinical evidence regarding use of marijuana for
medical purposes, and has concluded more research is needed, especially
related to clinical trials. VA is currently supporting a clinical trial
of cannabidiol for PTSD based upon a strong design and rationalized
mechanism in a trial that will assess risks and benefits. VA has also
encouraged other research on possible medical uses for marijuana and
compounds or products derived from it. For all these reasons, VA is not
supportive of this proposed legislation.
H.R. 1647 - Veteran Equal Access Act
This bill would require VA to authorize its physicians and other
health care providers to provide recommendations and opinions to
Veterans who are residents of states with state-approved marijuana
programs regarding participation in such programs and to complete forms
reflecting such recommendations and opinions.
The Veterans Health Administration's (VHA) policy prohibiting VA
providers from recommending or making referrals to or completing
paperwork for Veteran participation in state marijuana programs is
based on guidance provided to VA by the United States Drug Enforcement
Administration (DEA), the agency with authority to interpret the
Controlled Substances Act (CSA).
Under CSA, marijuana is a schedule I controlled substance with a
high potential for abuse and has no currently accepted medical use in
treatment in the United States. DEA has advised VA there is no
provision of CSA that would exempt from criminal sanctions a VA
physician who acts with intent to provide a patient with the means to
obtain marijuana, including by filling out forms for state marijuana
programs. VA defers to the Department of Justice (DOJ) to determine the
legal effect of the phrase ``notwithstanding any other provision of
law'' on the enforcement of CSA against VA providers who might assist
Veterans in participating in state-approved marijuana programs.
VA encourages its providers to discuss marijuana use with Veterans
who are participating in state-approved marijuana programs, but we do
not support VA providers prescribing marijuana to Veterans and so do
not support this bill. The clinical benefit of most products derived
from the marijuana plant is still not proven scientifically, and VA
must provide consistent, safe, science-based care for all Veterans.
Further, the marijuana industry is largely unregulated, and products
are often not accurately labeled, so providers cannot ascertain the
strength and levels of active ingredients in the product being used by
a particular patient, complicating medication management and treatment.
H.R. 2191 - Veterans Cannabis Use for Safe Healing Act (Veterans CUSH
Act)
Section 2(a) of H.R. 2191 would prohibit VA from denying a Veteran
a benefit under the laws administered by the Secretary because of their
participation in a state-approved marijuana program. Section 2(b) would
require the Secretary to ensure that VA providers discuss marijuana use
with patients, adjust treatment plans accordingly, and record
information about marijuana use in the patient's medical records. In
addition, section 2(c) of the bill would authorize VA providers to
furnish recommendations and opinions to Veterans who reside in states
with state-approved marijuana programs regarding participation in such
programs.
VA does not support this bill. Sections 2(a) and 2(b) are
unnecessary. VHA policy, VHA Directive 1315, Access to VHA Clinical
Programs for Veterans Participating in State-Approved Marijuana
Programs, is very clear that Veterans may not be denied VHA services
solely because they are participating in state-approved marijuana
programs. Veterans may continue to receive VHA benefits, and providers
should discuss with patients how their use of state-approved medical
marijuana to treat medical or psychiatric symptoms or conditions may
affect other clinical decisions (e.g., discuss how marijuana use may
impact other aspects of the overall care of the Veteran such as
treatment for pain management, PTSD, or substance use disorder, or how
it may interact with other medications the Veteran is taking). VA
treatment plans may be modified based on marijuana use on a case-by-
case basis and in partnership with the Veteran.
The content of Section 2(c) is the same as one of the requirements
of H.R. 1647, discussed above. As noted in the previous discussion of
that bill, VHA's policy prohibiting VA providers from recommending or
making referrals to (or completing paperwork for) Veteran participation
in state marijuana programs is based on guidance provided to VA by DEA,
the agency charged with interpreting the CSA. Also, as noted, DEA has
advised VA that the CSA contains no provision that would exempt a VA
physician, who acts with intent to provide a patient with the means to
obtain marijuana, including by filling out state marijuana program
forms, from criminal sanctions, and VA would defer to DOJ on the
enforcement of CSA against VA providers.
If the intent of the bill is simply to authorize VA providers to
discuss marijuana use with their patients, such clinical discussions
are already allowed under VHA policy, as discussed above.
Draft ``GAO MOU and MOA'' Bill
This bill would direct the Comptroller General of the United States
to conduct an assessment of the effectiveness of all memoranda of
understanding and memoranda of agreement entered into by the Under
Secretary of Health and non-VA entities relating to (1) suicide
prevention activities and outreach and (2) the provision and
coordination of mental health services in the last 5 years.
VA defers to the Comptroller General for views on this bill, as the
bill relates to action to be taken by the Government Accountability
Office and has no direct cost implications for VA. Although VA defers
to the Comptroller General on this bill, we note our belief that the
Congress already has the authority to request this information without
legislation.
Draft GAO Suicide Prevention Bill
This proposed legislation would direct the Comptroller General of
the United States to conduct an assessment of the responsibilities,
workload, and vacancy rates of VA suicide prevention coordinators.
VA defers to the Comptroller General for views on this bill, as the
bill relates to action to be taken by the Government Accountability
Office and has no direct cost implications for VA. In any case, a new
Suicide Prevention Coordinator (SPC) program guidebook and Suicide
Prevention Program directive are currently in development, which will
include guidance on responsibilities, workload, training, and staffing
levels for SPCs. VA's Mental Health Hiring Initiative is active and
addresses current hiring plans for, as well as retention of, SPCs.
Draft Suicide Notification Bill
This bill would require VA to submit notification of a Veteran
suicide death or suicide attempt that occurs in, or on the grounds of,
a VA facility to the Committees on Veterans' Affairs of the House of
Representatives and Senate and members of Congress representing the
district of the facility, within 7 days of the event. Information is to
be provided by VA within 60 days regarding the Veteran's VA enrollment
status; military service period; marital, employment, and housing
status; and confirmation that immediate family members have been
provided notice of any VA support or assistance for which the family
may be eligible.
VA could support this legislation provided certain clarifying
technical changes are made and provided that the Congress provides the
necessary resources. We would be pleased to work with the Subcommittee
on such changes. Also, it should be noted that section 2(B)(i) of the
bill, which calls for providing the enrollment status of the Veteran
for health care, might not satisfy the intent of this legislation's
reporting requirement, since certain categories of Veterans and certain
treatment authorities do not require Veterans to be enrolled.
We estimate that enactment of this bill would result in costs of
$507,000 for FY 2020, $2.739 million over the 5-year period from FY
2020 through FY 2024, and $6.054 million over the 10-year period from
FY 2020 through FY 2029.
Draft ``VA - Whole Health'' Bill
This draft bill would require VA to submit to Congress within 180
days after the date of enactment a report on the implementation of VA's
memorandum, dated February 1, 2019, on the subject of Advancing Whole
Health Transformation Across VHA (hereafter referred to as the
``Memorandum''). Specifically, the report would need to include an
analysis of the accessibility and availability of each of the following
12 services with respect to the implementation of the Memorandum: (1)
massage therapy; (2) chiropractic services; (3) whole health clinician
services; (4) whole health coaching; (5) acupuncture; (6) healing
touch; (7) whole health group services; (8) guided imagery; (9)
meditation; (10) clinical hypnosis; (11) yoga; and (12) tai chi or qi
gong. The report must also include the same analysis for any other
service the Secretary determines appropriate.
The Whole Health System includes three components: 1) Empower: The
Pathway - in partnership with peers, empowers Veterans to explore
mission, aspiration, and purpose and begin personal health planning. 2)
Equip: Well-being Programs equip Veterans with self-care tools, skill-
building, and support. Services may include proactive Complementary and
Integrative Health (CIH) approaches such as yoga, tai chi, or
mindfulness. 3) Treat: Whole Health Clinical Care - in VA, the
community, or both, clinicians are trained in Whole Health and
incorporate CIH approaches based on the Veteran's personalized health
plan. VA staff have been working with Veterans around the country to
bring elements of this Whole Health approach to life. In conjunction
with VA's implementation of section 933 of Public Law (P.L.) 114-198,
the Comprehensive Addiction and Recovery Act of 2016, VA began
implementation of the full Whole Health System at 18 flagship
facilities in the beginning of FY 2018. This constituted the first wave
of facilities to be included in the national deployment of VA's Whole
Health System.
Flagship facility implementation of the Whole Health System is
proceeding over a 3-year period (FY 2018 - FY 2020) and is supported by
a well-proven collaborative model which drives large scale
organizational change. In addition to the implementation guide,
flagship facilities are receiving education and training, resources and
tools, and on-site support. These sites also have designated funding
for the start-up costs needed. In addition, Veteran outcomes, Veteran
satisfaction, cost, and utilization rates are being tracked as well as
the impact, to the extent determinable, of the Whole Health approach on
opioid safety, suicide prevention, and impact on the VHA workforce.
More specifically, the Memorandum announces the launch of Whole
Health Learning Collaborative 2: Driving Cultural Transformation and
requests that each Veterans Integrated Service Network identify 2 sites
to participate, for a total of 36 sites across VA (separate from the 18
flagship facilities mentioned previously). This collaborative
initiative will help further Whole Health delivery and innovation. The
collaborative kick-off is scheduled for June 2019 with selection of
sites currently underway. These 36 sites will then be supported through
the subsequent 18 months as part of this Learning Collaborative
process. At this time, specific start-up funding for the 36 sites has
not been identified.
It is unclear if the drafters intended to limit the mandated
analysis and report requirement to the 36 sites participating in the
Learning Collaborative (under the Memorandum.) In other words, the
draft bill's incorporation of the Memorandum by specific reference
could, in operation, limit us to the 36 sites participating in the
Learning Collaborative initiative. Congress may wish to consider
extending the draft bill's reporting requirement to the 170 VAMCs and
myriad outpatient sites operated by the Department.
VA supports this draft bill, and we would look forward to working
with you. The reporting required by this bill can be produced by
current VA staff and would require no additional resources to complete.
Madam Chair, I conclude my remarks with the following highlights of
VA's suicide prevention efforts. VA is moving from a purely hospital-
based suicide prevention model to a public health model. We continue to
care for those in crises, with VA suicide prevention coordinators
managing care for almost 11,000 Veterans who are clinically at high-
risk for suicide. VA's Recovery Engagement and Coordination for Health
- Veterans Enhanced Treatment (REACH-VET) program uses predictive
analytics to identify Veterans with high statistical risk for suicide.
Annually, 30,000 Veterans receive care review and outreach to ensure
they are well engaged in care and their needs are being met.
Under VA's new universal screening for suicidal intent, more than
2,057,000 Veterans have received a standardized risk screen since
October 1, 2018; more than 62,000 of these Veterans have received more
complex screening based on a positive initial screen; and more than
8,000 have received a full clinical assessment after screening
positive.
At the same time, we are implementing the National Strategy for
Veteran Suicide Prevention and are aggressively pursuing partnerships
necessary to help us reach all Veterans. Just as suicide is a complex
issue with no single cause, no single organization can end Veteran
suicide alone. Every person, system, and organization must work
together to save lives. We have, for example, in partnership with
Johnson & Johnson, released a Public Service Announcement (PSA), ``No
Veteran Left Behind,'' featuring Tom Hanks via social media and a
communications plan led by Johnson & Johnson. VA continues to use the
#BeThere Campaign to raise awareness about mental health and suicide
prevention and educate Veterans, their families, and communities about
the suicide prevention resources available to them. The National Action
Alliance helped spread the #BeThere campaign to hundreds of partners
using #BeThere and the Veterans Crisis Line information during 2018
Suicide Prevention Month activities.
We created more than 30 new cross-sector partnerships to involve
peers, family members, and communities in preventing Veteran suicide.
We also deliver monthly partnership updates to include content about
the S.A.V.E. online suicide prevention training video to 60 informal
and formal partners, providing communications materials (blog posts,
social media, and emails) for use. The acronym S.A.V.E. summarizes the
steps needed to take an active and valuable role in suicide prevention
(Signs of suicidal thinking, Ask questions, Validate the person's
experience, and Encourage treatment and expedite getting help).
As you may know, this month we started working with you and other
Members of Congress to spread awareness about the important topic of
Veteran suicide through a PSA drive on Capitol Hill. VA's suicide
prevention experts developed two suggested PSA scripts that Members can
customize for their specific locations and audiences. The scripts are
designed to use safe messaging best practices, provide hope, encourage
help-seeking, and direct viewers to available mental health and suicide
prevention resources. Thank you to those of you who have already
developed your PSAs. If you have not yet developed yours, you can
schedule time to record your PSA at either the House or Senate
Recording Studio. Please let us know if VA can provide you with any
further assistance, and we look forward to our continued
collaborations.
Conclusion
This concludes my statement. I would be happy to answer any
questions you or other Members of the Committee may have.
Prepared Statement of Joy J. Ilem
Chairwoman Brownley and Members of the Subcommittee:
Thank you for inviting DAV (Disabled American Veterans) to testify
at this legislative hearing of the Subcommittee on Health. As you know,
DAV is a non-profit veterans service organization comprised of more
than one million wartime service-disabled veterans that is dedicated to
a single purpose: empowering veterans to lead high-quality lives with
respect and dignity. DAV is pleased to offer our views on the bills
under consideration by the Subcommittee.
H.R. 100, the Veterans Overmedication and Suicide Prevention Act of
2019
This bill would require VA to enter into a contract with the
National Academies of Sciences, Engineering and Medicine to
retrospectively study suicides of any veteran using Department of
Veterans Affairs (VA) facilities for health care treatment for any of
the past five years ending with the date of enactment. It would require
the age, gender, race, and ethnicity among studied veterans and include
deaths considered violent or accidental among veterans' suicides. In
particular, the study would evaluate prescription and other drug
utilization, including VA's prescribing of medications with black box
warning labels, use of multiple prescription drugs and the number of
instances when first line treatment therapies without use of
prescription medications were used with particular regard for veterans
with diagnosed conditions of posttraumatic stress, traumatic brain
injury (TBI), military sexual trauma (MST), anxiety and depression. The
study would also consider staffing levels, VA's use and barriers to use
of marital and family counselors, and a compilation of pain management
protocols being used while prescribing medications for other high risk
diagnoses.
It appears the study called for by this legislation is intended to
identify problematic prescribing patterns for mental health care
conditions in the VA that may be attributable to suicides among
veterans. While there have been cases of documented over prescribed or
inappropriate prescription drug therapy, we believe the information
called for by this legislation could paint a distorted or inaccurate
picture of mental health practices within VA. Additionally, we believe
most of the data and analysis called for in this measure can be
obtained through VA.
It is difficult to determine whether the drugs prescribed by VA for
a particular patient were appropriate unless each individual case is
studied. In calling for the number of instances in which a non-
medication frontline intervention was attempted and determined to be
``ineffective'' for the veteran, the bill also seems to mistakenly
assume that VA's clinical practice guidelines do not include use of
prescription drugs. In fact, VA's training for and use of evidence-
based or ``front line'' practices for conditions such as post-traumatic
stress disorder (PTSD), MST, depression and anxiety include clinical
practice guidelines for prescribing medications when clinically
indicated, and prescription drugs are often given concurrently with
other types of treatment.
VA's use of evidence-based practices also far exceeds the use of
such practices in the private sector. In one RAND study, investigators
determined that only about 2 percent of private sector providers in New
York were adequately prepared to meet veterans' needs by making use of
evidence-based clinical practice guidelines, appropriately screening
for and managing conditions common to veterans such as TBI, PTSD and
MST, or asking about military status and being culturally competent in
delivering care. \1\
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\1\ Tanielian, Terri, Carrie M. Farmer, Rachel M. Burns, Erin L.
Duffy, and Claude Messan Setodji, Ready or Not? Assessing the Capacity
of New York State Health Care Providers to Meet the Needs of Veterans.
Santa Monica, CA: RAND Corporation, 2018. https://www.rand.org/pubs/
research--reports/RR2298.html. Also available in print form.
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VA's patients are often clinically complex and have a variety of
mental and physical disorders that frequently require comprehensive
care and supportive social services. Veterans who are suicidal often
have a multitude of issues with which they are struggling such as
homelessness, poverty, unemployment, mental and physical disabilities,
war-related readjustment issues, substance use and family dissolution.
Without fully understanding the unique complications within this
population, this study may unfairly suggest VA prescribing practices
are excessive and somehow different than those of other health care
providers. In our opinion without any basis of comparison, this study
would not serve to enlighten clinical practice.
DAV certainly agrees that research is essential to determine
dangerous or ineffective clinical practices, but does not believe that
this study, as proposed, will be able to provide clear evidence of use
of such practices in VA. Because of its utilization of a centralized
electronic health record with a pharmaceutical component, VA is able to
collect and analyze data about polypharmacy issues and regularly does
so to ensure that it continues to improve patient safety, quality of
care and clinical outcomes.
DAV agrees it is important for VA to look at case studies of
veterans prescribed medications with black box warnings to determine if
prescribing was properly indicated and use appropriately monitored for
certain patients if it is not doing so already. We also agree with
sections in the bill calling for identifying the adequacy of mental
health staffing levels, including VA's use of marriage and family
counselors. In accordance with DAV Resolution No. 293, we support
enhancing resources to ensure that VA mental health providers are able
to provide timely comprehensive mental health services to veterans who
need such care. We also believe more research is necessary to determine
the root causes of higher suicide rates among veterans in addition to
identifying the most effective monitoring systems and therapies for
reducing rates of suicide and suicidal ideation for all veterans and
certain sub-populations, such as women veterans. While we support
certain sections in H.R. 100, we urge the subcommittee to work with VA
subject matter experts to revise provisions within this bill to advance
improved clinical practice.
H.R. 712, the VA Medicinal Cannabis Research Act of 2019
DAV supports and urges swift passage of H.R. 712, the VA Medicinal
Cannabis Research Act of 2019. This is a bipartisan bill that would
direct the VA to perform clinical research to determine whether
cannabis is able to reduce symptoms associated with chronic pain such
as inflammation, sleep disorders, spasticity, and agitation and effects
on the use or dosage of opioids, benzodiazepines or alcohol for
veterans with PTSD. DAV Resolution No. 023, adopted by our members
during our 2018 National Convention, calls for comprehensive and
scientifically rigorous research by the VA into the therapeutic
benefits and risks of cannabis and cannabis-derived products as a
possible treatment for service-connected disabled veterans.
At this time, there are few definitive answers about risks and
benefits associated with the use of cannabis on various medical
conditions and illnesses. Research is necessary to help clinicians
better understand the safety and efficacy of cannabis use for specific
conditions that co-occur with other common conditions found in the
veteran population such as chronic pain and post-traumatic stress.
H.R. 1647, the Veterans Equal Access Act
H.R. 2191, the ``Veterans Cannabis Use for Safe Healing Act'' or the
``Veterans CUSH Act''
The December 8, 2017 Veterans Health Administration (VHA) Directive
1315 sets out the Department's policy on access to VHA clinical
programs for veterans participating in a State-approved marijuana
program. VA's policy encourages VHA clinicians to discuss and provide
information to veterans about cannabis as part of comprehensive care
planning, and adjust individual treatment plans as necessary. VA's
policy also ensures veterans that participation in state marijuana
programs will not affect their eligibility for VA care and services.
However, while several states have approved the use of marijuana
for medical and/or recreational use, Federal law classifies marijuana
as a Schedule I Controlled Substance, which makes it illegal to be
prescribed, or for a prescription to be filled by the Federal
government. VA's policy is that VA employed providers may not recommend
or assist veterans to obtain cannabis unless otherwise approved by the
Food and Drug Administration for medical use, such as the one cannabis-
derived seizure medication Epidiolex, and three cannabis-related drug
products; Marinol, Cesamet and Syndros.
H.R. 1647, the Veterans Equal Access Act and H.R. 2191, the
Veterans CUSH Act, are aimed at clarifying VA's policy, which currently
treats recommending marijuana as equivalent to prescribing marijuana.
This measure would allow VA clinicians to provide recommendations and
opinions, and to complete forms reflecting such recommendations and
opinions, to veterans regarding participation in state marijuana
programs. The CUSH Act adds that VA may not deny a veteran any VA
benefit due to the veteran participating in a State-approved marijuana
program and must discuss cannabis use with the veteran related to his
or her treatment plan.
DAV does not have a resolution specific to the issues addressed in
these bills and therefore, takes no position on H.R. 1647 or H.R. 2191.
Draft bill, to direct the Comptroller General of the United States to
conduct an assessment of the responsibilities, workload, and vacancy
rates of Department of Veterans Affairs suicide prevention coordinators
This bill would require the Government Accountability Office (GAO)
to study the role of Suicide Prevention Coordinators within VA. The
study would be required to determine the adequacy and appropriateness
of training for these coordinators, if their caseloads are appropriate
and how much these factors vary across the system. It would also
determine who has responsibility for oversight of Suicide Prevention
Coordinators.
VHA Handbook 1160.01 states that its purpose is to standardize the
practice of mental health within VHA. It assigns ultimate authority for
ensuring program coherence and integrity to the Mental Health Executive
Council, which oversees facility wide practices in suicide prevention,
but since these councils are made up of professionals representative of
mental health practitioners, DAV believes lines of authority with
regard to Suicide Prevention Coordinators may be unclear. The Handbook
also defines the responsibilities of Suicide Prevention Coordinators,
making them full-time positions and requiring that they have additional
support from medical centers to perform their duties if necessary.
These individuals are to report monthly to mental health leadership and
the National Suicide Prevention Coordinator on veterans who attempt or
complete suicide, but there are otherwise no requirements for oversight
defined.
Because of these ambiguities and the importance of the Suicide
Prevention Coordinator's responsibilities, we agree this study could
yield important information and thus support this draft bill.
Draft bill, to direct the Secretary of Veterans Affairs to submit to
Congress a report on the Department of Veterans Affairs advancing of
whole health transformation
This draft legislation would require the VA to report on access and
availability on each of several complementary and integrative medicine
practices, including: massage; chiropractic services; acupuncture;
meditation; yoga, Tai Chi or Oi sang; and Whole Health group services.
We are pleased to support this draft measure focused on advancing
VA's Whole Health transformation in accordance with DAV Resolution 277,
which supports the provision of comprehensive VA health care services
to enrolled veterans, and specifically calls upon Congress to provide
funding to guarantee access to a full continuum of care, from
preventive through hospice services, including alternative and
complementary care such as yoga, massage, acupuncture, chiropractic and
other non-traditional therapies.
DAV is aware that some VA facilities have set limits upon provision
of these practices-for example, a veteran may not be able to get both
yoga and acupuncture. Facilities may also limit the number of visits or
treatments allowed or have long wait times for massage and other
popular services. These limitations are likely the result of policy
that encourages use of, but does not specifically require, these
services. The report this draft bill calls for would help to determine
the extent to which these services are available to veterans that need
them in accordance with VHA Directive 1137. To provide a more complete
picture, DAV suggests that the study also include integrative services
VA provides through its Veterans Community Care Program (VCCP) Network.
Draft bill, to direct the Comptroller General of the United States to
conduct an assessment of all memoranda of understanding and memoranda
of agreement between Under Secretary of Health and non-Department of
Veterans Affairs entities relating to suicide prevention and mental
health services
This draft bill would require GAO to report on the effectiveness of
VA memoranda of agreement and memoranda of understanding with non-VA
providers to carry out suicide prevention activities and mental health
case management services, including regional variations, and care for
certain populations such as women, minorities, older, and younger
veterans. It requires GAO to look at staffing, licensure and
accreditation and other relevant program features to determine if these
entities are adequately addressing roles as identified in MOUs and
MOAs.
DAV has been disappointed in the lack of focus on required quality
standards proposed for non-VA providers who will participate in the
MISSION Act community care program. Ensuring veterans, who are referred
by VA to the community or select private sector care, have access to
quality care is essential to good health outcomes. Notable research
institutions, such as RAND have questioned private providers'
understanding of the complexity of treating veteran patients and
conditions specially related to military service. In accordance with
DAV Resolution No. 293, which calls on VA to collect data to ensure the
quality and integrity of mental health services for veterans we support
this draft bill which would provide an additional layer of oversight as
VA moves toward more access to care in the community and expand its
role in suicide prevention to all at-risk veterans using a public
health model.
Draft bill, to direct the Secretary of Veterans Affairs to provide to
Congress notice of any suicide or attempted suicide of a veteran in a
Department of Veterans Affairs facility
This draft measure would require VA to notify the Congressional
Committees on Veterans' Affairs in the case of suicide or attempted
suicide of any veteran that occurs in or on the grounds of a VA
facility. The bill further requires information about the veteran
including military service, age, marital, housing and employment
status, and the date of VA's last documented contact with the veteran.
While DAV has no specific resolution concerning this issue we
understand the Committees' desire for VA to communicate any suicides or
attempted suicides that occur on VA grounds to Congress, thus we have
no objection to favorable consideration of this bill.
Chairwoman Brownley, this concludes my testimony. DAV would be
pleased to respond to any questions from you or Subcommittee members
concerning our views on the bills under consideration today.
Prepared Statement of Carlos Fuentes
Chairwoman Brownley, Ranking Member Dunn, and members of the
subcommittee, on behalf of the women and men of the Veterans of Foreign
Wars of the United States (VFW) and its Auxiliary, thank you for the
opportunity to provide our remarks on legislation pending before this
subcommittee.
H.R. 712, the VA Medicinal Cannabis Research Act of 2019
This legislation would require the Department of Veterans Affairs
(VA) to conduct a double blind scientific study on the efficacy of
medical cannabis. The VFW is proud to support this important bill and
thanks this subcommittee for its consideration.
VA is making concerted efforts to ensure it appropriately uses
pharmaceutical treatments when providing mental health care. Under the
Opioid Safety Initiative, VA has reduced the number of patients to whom
it prescribes opioids by more than 22 percent. Prescribed use of
opioids for chronic pain management has unfortunately led to addiction
to these drugs for many veterans, as well as for many other Americans.
VA uses evidence-based clinical guidelines to manage pharmacological
treatment of post-traumatic stress disorder, chronic pain, and
substance use disorder (SUD) because medical trials have found them to
be effective. To reduce the use of high-dose opioids, VA must expand
research on the efficacy of non-traditional medical therapies, such as
medical cannabis and other holistic approaches.
Medical cannabis is currently legal in 33 states and the District
of Columbia. This means veterans are able to legally obtain cannabis
for medical purposes in more than half the country. For veterans who
use medical cannabis and are also VA patients, they are doing this
without the medical understanding or proper guidance from their
coordinators of care at VA. Many states have conducted research for
mental health, chronic pain, and oncology at the state level. States
that have legalized medical cannabis have also seen a 15-35 percent
decrease in opioid overdose and abuse. A comprehensive study by the
National Academy of Sciences and the National Academic Press also
concluded that cannabinoids are effective for treating chronic pain,
chemotherapy-induced nausea and vomiting, sleep disturbances related to
obstructive sleep apnea, multiple sclerosis spasticity symptoms, and
fibromyalgia--all of which are prevalent in the veteran population.
While VA has testified that it has the authority to study Schedule 1
drugs, it has failed to do so and veterans are tired of waiting for VA.
VFW-Student Veterans of America Fellow Christopher Lamy, an Army
veteran and Louisiana State University law school student, focused his
semester-long research project and advocacy effort on this important
bill. Chris' research discovered that veterans experience chronic pain
at 40 percent higher rates than non-veterans and if not properly
treated, such chronic pain often leads to depression, anxiety, and
decreased quality of life. Chris also found that states with medical
cannabis programs have, on average, a 25 percent lower rate of death
from opioid overdose than non-medical cannabis states.
Veterans Health Administration (VHA) Directive 1315, Access to VHA
Clinical Programs for Veterans Participating in State-Approved
Marijuana Programs, provides protections for veterans who use medical
cannabis. However, Chris found that veterans who discuss their use of
medical cannabis with their doctors are ostracized and have their
medications changed or discontinued. The fear of reprisal for medical
cannabis prevents veterans from disclosing information to their VA
health care providers, which can lead to problems caused by drug
interactions. This legislation would prohibit VA from making
eligibility determinations for benefits based on participation in the
study. To ensure veterans who participate in the study do not have
their VA health care impacted, the VFW recommends this subcommittee
amend the bill to prohibit VA from denying or altering treatment to
veterans who participate in the study. Doing so would provide veterans
peace of mind.
H.R. 1647, the Veterans Equal Access Act
This legislation would authorize VA health care providers to
provide recommendations for participation in state-approved medical
marijuana programs. The VFW agrees with the intent of this legislation,
but cannot offer its support at this time.
The VFW agrees that veterans who rely on the VA health care system
must have access to medical cannabis, if such therapies are proven to
assist in treating certain health conditions. Without such evidence, VA
would not have the authority to prescribe or provide medical cannabis
to veterans. The VFW believes it is unacceptable for VA providers to
recommend a treatment that they are unable to provide veterans and
force patients to pay for the full cost of such care. If VA recommends
a treatment plan, it must be able to provide required therapies or
prescriptions. That is why the VFW supports H.R. 712, which would
enable veterans to participate in medical cannabis research without
having to bear the full cost of treatment.
H.R. 2191, the Veterans Cannabis Use for Safe Healing Act
This legislation would require VA providers to discuss and record
veterans' use of medical cannabis and participation in state-approved
marijuana programs. It would also authorize VA health care providers to
recommend participation in such programs and prohibit VA from denying
veterans access to benefits solely based on their use of marijuana.
The VFW strongly supports provisions to protect veterans from
having their earned benefits eroded or denied simply based on their
participation in a state-approved marijuana program. Veterans who
participate in such programs must not fear that VA will take away
benefits they have earned and deserve. The VFW also believes it is
important for VA to properly track veterans who use medical cannabis.
However, the VFW is concerned VA may not implement the requirement to
record medical cannabis use as intended.
VHA Directive 1315, Access to VHA Clinical Programs for Veterans
Participating in State-Approved Marijuana Programs, instructs VA health
care professionals to record marijuana use ``into the `non-VA/herbal/
Over the Counter (OTC) medication section' of the Veteran's electronic
medical record.'' Yet, the VFW continues to hear from veterans who have
been recorded as having a SUD for testing positive for marijuana or
because their VA health care provider did not follow the guidance
included in the directive. Veterans who report participation in state-
approved marijuana programs must not be recorded as having a SUD. To
ensure the recording requirement is implemented properly, the VFW
recommends this subcommittee require VA to create diagnostic codes for
medical cannabis use or prohibit VA from recording such use as SUD.
This legislation would also authorize VA health care providers to
recommend participation in state-approved marijuana programs. As
discussed above, the VFW cannot support such authority if VA is unable
to provide a recommended course of treatment.
H.R. 100, the Veteran Overmedication and Suicide Prevention Act of 2019
This legislation would commission research and require that VA
report data on veteran suicides. The VFW supports this legislation and
has a recommendation to improve it.
In partnership with the Department of Defense, the Centers for
Disease Control and Prevention, and other Federal agencies, VA has
compiled the most comprehensive data and analysis of veteran suicides
that has ever existed. The most recent analysis of veteran suicide data
from 2016 found suicide has remained fairly consistent within the
veteran community in recent years. An average of 20 veterans and
service members die by suicide every day. While this number must be
reduced to zero, it is worth noting that the number of veterans who die
by suicide has remained consistent in recent years, while non-veteran
suicides have continued to increase.
However, VA's National Suicide Data Report is delayed by two years
and misses certain elements which this legislation would include, such
as the impact of staffing levels on suicide prevention efforts. The VFW
has long argued that VA's lack of staffing models and inability to
properly staff its health care facilities impact its ability to provide
timely and high-quality health care to veterans who face mental health
crises.
The report commissioned by this legislation would be conducted by a
third party, which would also ensure VA bias is eliminated. While the
majority of veterans who die by suicide every day are not active users
of the VA health care system, VA must do everything possible to save
the lives of those who rely on VA. An external analysis of VA practices
and procedures would ensure VA is doing what it necessary to save the
lives of the six VA health care users who die by suicide every day.
To better assist all veterans, the VFW urges this subcommittee to
require the study to include research and data collection on the 14
veterans and service members who die by suicide every day without
receiving VA health care. This legislation would limit the study to
veterans who have used VA health care within the past five years. Doing
so would exclude about two-thirds of veterans who die by suicide each
day without any contact with VA. The VFW urges this subcommittee to
amend this legislation to include and analyze the demographics,
illnesses, socioeconomic status, and military discharges of such
population. There are questions that need to be answered in order to
properly address this epidemic: did those 14 use private sector care?
Were they eligible to use VA? Were they among the many who were
discharged without due process for untreated or undiagnosed mental
health disorders? Were they discharged for unjust and undiagnosed
personality disorders due to transgenderism or during the era of
``Don't Ask, Don't Tell?'' Have they used other VA benefits such as the
GI Bill?
H.R. 2333, the Support for Suicide Prevention Coordinators Act
The VFW supports this legislation, which would commission an
assessment of VA suicide prevention coordinators.
Suicide prevention coordinators are instrumental in the efforts to
reduce suicides among veterans. These caring and hardworking
individuals are at the front line of suicide prevention efforts at VA
medical facilities, including case management of veterans who are at
high risk of suicide. The legislation would rightfully evaluate if VA
is properly supporting those who support veterans in their time of
greatest need.
Draft Legislation to Submit to Congress a Report on VA Advancing of
Whole Health Transformation
The VFW supports this legislation, which would require VA to report
on its implementation of complementary and integrative therapies
throughout the VA health care system.
Countless veterans have experienced first hand the dangerous side
effects of pharmacotherapy. Many of these medications, if incorrectly
prescribed, have been proven to render veterans incapable of
interacting with their loved ones and even contemplate suicide. VA must
ensure it affords veterans the opportunity to access effective
treatments that minimize adverse outcomes.
Thanks to the VFW-supported Jason Simcakoski Memorial and Promise
Act, medications are being more closely monitored. Through VA's Opioid
Safety Initiative, opioids are being prescribed on a less frequent
basis for mental health conditions and are better monitored for
negative consequences such as addiction. However, many veterans report
being abruptly taken off opioids they have relied on for years to cope
with their pain management, without receiving a proper treatment plan
to transition them to alternative therapies. Doing so leads veterans to
seek alternatives outside of VA or to self-medicate.
With the growing body of research on the efficacy of complementary
and integrative therapies, such as meditation, acupuncture, and massage
to treat mental health conditions and manage pain, the VFW believes
more work must be done to ensure veterans are afforded the opportunity
to receive these safe and effective alternatives to pharmacotherapy.
This legislation would provide oversight of VA's efforts to taper
veterans off high-dose opioid and switch to effective alternatives.
Madam Chairwoman, this concludes my testimony. I am prepared to
take any questions you or the subcommittee members may have.
Prepared Statement of Stephanie Mullen
Chairwoman Brownley, Ranking Member Dunn, and distinguished members
of the subcommittee, on behalf of Iraq and Afghanistan Veterans of
America (IAVA) and our more than 425,000 members worldwide, I would
like to thank you for the opportunity to testify here today on the
pending legislation before the subcommittee.
As the Research Director for IAVA, I get to take the collective
experiences and views of IAVA members to support our policy and
programmatic work - giving numbers to the narratives of IAVA members
everyday. I am truly honored to serve those who have served this great
nation and feel a special privilege in working with the post-9/11
generation, many of whom are my teachers, leaders, and friends, on the
issues that impact them most. I am the product of a military family;
the daughter of a retired U.S. Air Force Lieutenant Colonel who spent
twenty years of her life fighting on the front lines - from Kuwait in
the First Gulf War to being one of the few women in leadership roles
during the 1970s, 80s, and 90s. And yet, my mom still gets asked where
her husband is when she walked into VA facility and constantly deals
with many of the wounds of war we see similarly in the post-9/11
generation like chronic pain and arthritis. So many of the issues IAVA
tirelessly advocates for directly impacts the people I love most, and
it drives my work to ensure that veterans of all generations are
receiving the best care and treatment possible across all areas of
society.
Support for Veteran Medicinal Cannabis Use is an incredibly
important part of our work; it is why it's one of our Bix Six
Priorities for 2019, which includes, in addition to Support for Veteran
Cannabis Use, the Campaign to Combat Suicide, Defense of Education
Benefits, Support and Recognition of Women Veterans, Government Reform
for Veterans, Support for Injuries from Burn Pits and Toxic Exposures.
For years, IAVA members have been supportive of medical cannabis.
In IAVA's latest Member Survey, 83% of IAVA members agree that cannabis
should be legal for medical purposes. And a resounding 90% believe
cannabis should be researched for medicinal uses. IAVA members are
already there in terms of cannabis research, and it's time for the
Department of Veterans Affairs (VA) to catch up.
IAVA is proud to support the VA Medicinal Cannabis Research Act
(H.R. 712) which will advance research and understanding around the
safety and effectiveness of cannabis to treat the signature injuries of
war. At this time, we have limited evidence on cannabis' effectiveness
to treat the injuries that impact huge swaths of the post-9/11
generation.
Without research done by VA surrounding cannabis, veterans will not
have conclusive answers to how cannabis can aide their health needs.
This is unacceptable. VA houses some of the most innovative and best-
in-class research this country has to offer. It should not be shutting
its doors on a potentially effective treatment option because of
politics and stigma. This nation's veterans deserve better.
In IAVA's most recent Member Survey, a staggering 72% of veteran
and military members reported suffering from chronic pain. Sixty-six
percent report joint injuries, and over 50% report either PTSD,
anxiety, or depression. Cannabis may be an effective treatment option
for all of these service-connected injuries; but we must invest in the
research to ensure it is. The VA Medicinal Cannabis Research Act will
build on this evidence and provide further data to explore the
effectiveness of cannabis as a treatment option.
However, research takes time - years in fact. And there are
veterans suffering with the signature injuries of war now. Thirty-three
states and the District of Columbia have already legalized medical
cannabis. Unfortunately, VA's lackadaisical approach to cannabis forces
many veterans to circumvent VA to access cannabis. In just the last
month, over 100 IAVA members have shared their stories of their
cannabis use, with dozens sharing how VA retaliated against or
mishandled them and dozens more sharing that they flat out refuse to
tell VA about their use. Left unchecked, this practice is harmful and
dangerous.
VA's policies inhibit realistic discussion and open conversations
around cannabis. While current VA policy allows for clinicians to talk
to their veteran patients about cannabis, VA clinicians are unable to
recommend cannabis to their patients, are unable to fill out state
cannabis medical forms, and are unable to recommend the best programs
and options for their patients.
It is unrealistic to think these limitations do not have negative
impacts. Ensuring clinicians have a full view of what their patients
are taking and experiencing is paramount to ensuring the veteran is
getting the best treatment and care possible. But, if veterans are
unable to have this open discussion or feel unwelcome to do so, it can
lead to potentially devastating consequences. The access is there, and
if veterans are unable to go through VA to get medical cannabis,
they'll go around it. But they shouldn't have to; VA care is an earned
benefit for our nation's veterans, they shouldn't feel that they have
to hide and circumvent VA to access a standard of care their civilian
counterparts access easily.
We know this is already occurring from IAVA members nationwide.
Twenty percent of IAVA members report using cannabis for medicinal use
and of those, only 31% have talked to their doctor about their cannabis
use and 24% either do not feel comfortable or feel slightly comfortable
talking about their cannabis use with their doctors. For the vast
majority of those that use cannabis, they are not talking to their
doctors about their cannabis use.
For just one of these stories, we have to look no further than our
IAVA Member Leaders. After serving for four and half years in the Army,
one IAVA Member Leader was medically retired with service-connected
migraines, traumatic brain injury and post-traumatic stress disorder.
He was later diagnosed with an autoimmune disorder, fibromyalgia, that
his doctors believe is related to burn pits and toxic exposures. He has
spent years in and out of doctors' offices for treatment of the
signature injuries of the post-9/11 conflicts, leading to a moment of
crisis and a suicide attempt just a few years ago.
Since then, he has found a way forward and found relief through
cannabidiol (CBD) and medical cannabis. However, because CBD and
medical cannabis are not a treatment option through VA, he had to find
alternative pathways to relief. He was forced to go outside of VA for
health care and pay out of pocket for treatments that have actually
helped him move forward in his life. He does not share this information
with VA for fear of retribution.
We must ensure that VA clinicians can have open and honest
discussions with their patients, allowing VA clinicians to recommend
cannabis to their patients when appropriate, and ensure VA clinicians
can submit forms for state medical cannabis programs for their veteran
patients.
For these reasons, IAVA is proud to support the Veterans Equal
Access Act (H.R. 1647) that will allow VA clinicians to provide
recommendations and fill out forms for state cannabis programs. IAVA is
also proud to support the Veterans Cannabis Use for Safe Healing Act
(H.R. 2191), which will codify current VA policy around medical
cannabis and ensure no veteran is punished for speaking to their
clinician about their cannabis use.
Additionally, IAVA is pleased to support DRAFT VA - Whole Health
bill which will examine VA's Whole Health initiative including the
complementary and alternative therapies provided within the program
like yoga, meditation, and chiropractic care. IAVA believes that whole
health is essential to the overall health and care of veterans. In
practice, 63% of IAVA members use complementary and alternative
therapies to treat a service-connected injury, most often using
meditation, chiropractic care, and yoga as therapies. While research is
still developing around many of these alternative treatments, they have
proven effective for IAVA members in treating the signature injuries of
war and we are encouraged to see interest in assessing the efficacy of
this program at VA.
Though cannabis reform is an important pillar in our advocacy
efforts, the top priority for IAVA and among our membership is suicide
prevention among troops and veterans. In 2016, the latest data
available, an average of 20 servicemembers and veterans die by suicide
each day accounting for over 7,000 deaths each year. Each one of these
deaths impacts an entire community: a family, friends, a military unit,
and the lives of each and every person that veteran or servicemember
touched. We often say one death by suicide is too many, and it is so
true, because every life has value and every death has impact far
beyond just one moment of crisis. IAVA members know this well; 65% of
our members know a post-9/11 veteran who has died by suicide, a rise of
19% since 2014. And when IAVA planted 5,520 flags on the National Mall
on October 3rd, 2018 to represent the 20 veteran and military souls
lost to suicide that year to date, many silently wept remembering
either those who were lost, or their own personal struggles.
When it comes to accurately understanding and addressing veteran
suicide, we must know the scope of the problem. While VA does release
veteran suicide data, it is often years behind and only as good as the
data provided by the Centers for Disease Control and the National Death
Index.
IAVA is pleased to see Congress address this issue through the
Veteran Overmedication and Suicide Prevention Act (H.R. 100), which
will commission a study through the National Academies of Sciences to
analyze violent and accidental veteran deaths. It has been a long
standing concern of IAVA that there are veteran deaths by suicide lost
in these other categories and we are not accurately counting all deaths
by suicide, potentially missing the scope of the problem. That means we
are also not targeting solutions accurately.
IAVA also thanks this Subcommittee for highlighting this public
health crisis by considering additional draft legislation. In 2015,
IAVA and our veteran service organization partners worked hand in hand
with Congress to pass the Clay Hunt Suicide Prevention for American
Veterans (SAV) Act. This landmark legislation focused on mental health
care and suicide prevention at VA. Progress has been made, in
particular, under Section 6 of the law in which partnerships with
nonprofit organizations specializing in mental health care were
expanded. But the Clay Hunt SAV Act is still lacking overall in timely
implementation of the loan repayment provision for psychiatrists and
the final report on the Clay Hunt peer support pilot programs showed a
systemic need for dedicated funding and increased staffing to ensure
the program is successful.
We are pleased to support draft legislation GAO MOU and MOA bill,
which will review and assess these and other partnerships between VA
and nonprofit organizations supporting VA's suicide prevention work.
Similarly, we are pleased to support Draft GAO Suicide Prevention bill
which will analyze the workload and reporting structure of VA's Suicide
Prevention Coordinators, those that serve at the front line of this
public health crisis. Increasing our understanding of veteran suicide,
the risk factors and protective factors, and the effectiveness of
suicide prevention programs at VA are all essential to tackling this
issue.
While we recognize and appreciate the intent behind DRAFT Suicide
Notification bill regarding veteran suicides on VA property, IAVA is
concerned that this legislation will not address the underlying issues
regarding these tragic events and violates the veterans' privacy and
personal information without the approval of the veterans' next of kin.
When a veteran dies by suicide on VA property, it indicates that the
foundation of trust between the public and VA has been catastrophically
undercut; VA is supposed to be where veterans go to get healthy and
seek treatment. When this moment of crisis happens on VA facility
grounds, it is truly heartbreaking and feels preventable. However, it
is important that we recognize that every death by suicide is
different, there are different risk factors, triggers, and moments of
crisis in each case and a death by suicide on VA property is just as
tragic and just as great a loss as a death by suicide in a veterans'
own home, car or workplace. Regardless, these tragic events should be a
call to action; to ensure that all VA policies and procedures
surrounding VA emergency mental health care, facility security, and
personnel training are up to date, acceptable, and being implemented
correctly. A failure in the system should and must be addressed. IAVA
recommends that the proposed legislation focus on these procedures and
policies at VA facilities that may be able to intervene in a moment of
crisis rather than the individual factors surrounding the tragic event
itself.
Members of the Subcommittee, thank you again for the opportunity to
share IAVA's views on these issues today. I look forward to answering
any questions you may have and working with the subcommittee in the
future.
Materials Submitted For The Record (Upon Request)
Draft Bill, Suicide Notification
Draft Bill, Suicide Prevention
Draft Bill, VA Whole Health
Draft Bill, Hon. Steube
H.R. 100
H.R. 712
H.R. 1647
[all]