What the VA Doesn't Get About Mental Health and Drug Treatment

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Something that is still poorly understood is how Veterans Affairs (VA) and other federal agencies have contributed to the opiate epidemic by not effectively addressing one of the thorniest problems in health care: the intersection between drug treatment and mental health care. About 50 percent of the most severely mentally ill people also have a substance abuse problem, while a little over half of drug addicts have at least one serious mental illness. Amid all the recent congressional horse-trading involving spending $45 billion more for opiate treatment to win over moderate Republican senators to support Obamacare repeal, practically no one seems to care if such added money would be spent effectively—or how the treatment industry and VA failures contribute to the relapses that mark addiction.

One solution is to offer effective, personalized, integrated treatment by staff cross-trained in mental health and drug addiction, along with such strategies as so-called motivational interviewing to spur change. But that requires actively monitoring VA clinicians, meaningfully measuring patient outcomes and holding staffers accountable for actually delivering evidence-based practices, none of which the VA generally does, according to repeated Government Accountability Office overview reports that have put the department on the "high-risk" list.

The results are striking when proven approaches are used. A seven-year Dartmouth follow-up study of inner-city Connecticut residents with schizophrenia and substance abuse who were offered those services found that 70 percent later didn't have psychiatric symptoms, and over 60 percent were no longer substance abusers. Unfortunately, relatively few state regulators and VA officials are paying attention to whether these services are being delivered properly—as many as 90 percent of clinics fail to do so. That could change if an independent assessment system—co-developed by Mark McGovern of Stanford Medical School, as described in detail in the book Inside Rehab—was widely applied across VA and Medicaid programs as it has been used in the past with select private and government-funded community treatment programs. But that's not likely to happen now, because starting about 2012, the federal Substance Abuse and Mental Health Services Administration pulled the plug on the evaluation program. The VA never promoted or used the methodology.