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Director's Letter

Mental health (MH) services are a persistent strength of VA care.¹ Not only are services more available and comprehensive than outside VA, they have been integrated with primary care services as part of a decade-old national strategy.² As a result, quality of MH care in VA regularly outpaces that provided in the private sector.³ Nonetheless, as outlined in this issue of FORUM, there is still progress to be made in substance use treatment, and research that is needed to get us there. One issue is how to better integrate specialty and primary care services when it comes to substance use and abuse, as outlined by Drexler and Burden. The opioid crisis has revealed the need to rethink our reliance on specialty addiction services, and to conduct the necessary research to help primary care teams take on a more expanded role in helping dependent patients. The State of the Art Conference on Opioid Use and Abuse last year highlighted the need to study a number of important questions, including how best to taper Veterans off of potentially dangerous doses of opioids, and how to increase the prescription of opioid agonists such as buprenorphine for patients with opioid use disorder. Both of these challenges will place PACT teams at the center. We hope a new research solicitation later this summer will kick start a new generation of research to keep VA ahead in the campaign to help patients with addictions. At the same time, we need to remember that despite the scourge of opioids, legal drugs, alcohol, and tobacco still kill many more Veterans, and that the country is undergoing a large national experiment in marijuana legalization with a general lack of good data on the potential risks of marijuana for Veterans.⁴ One doesn’t need to oppose legalization to acknowledge that marijuana is likely to become a problem for some Veterans and to observe that we don’t know much about how to detect harms of marijuana nor how best to intervene. The good news is that steady incremental progress against alcohol and tobacco has been a success story for VA and can continue to be a success story going forward. This success will require a close partnership among researchers and operational partners, combining research on what works best, implementation studies to tell us how to spread successful programs, and committed clinical leaders to build support and execute on their vision.

David Atkins, MD, MPH, Director, HSR&D

References

1. Independent Assessment of the Health Care Delivery Systems and Management Processes of the Department of Veterans Affairs—Assessment B (Health Care Capabilities). Santa Monica, CA: RAND. http://www.va.gov/opa/choiceact/docu- ments/assessments/assessment_b_health_care_capabilities.pdf
2. Families, Systems & Health 2010; 28:83–90.
3. Psychiatric Services 2016; 67:391–96.
4. Kansagara D, O’Neil M, Nugent S, et Benefits and Harms of Cannabis in Chronic Pain or Post-traumatic Stress Disorder: A Systematic Review. VA ESP Project #05-225; 2017. https://www.hsrd.research.va.gov/publications/esp/cannabis-REPORT.pdf