The pixels were barely dry on David Gorski’s lament over the expansive integration of pseudoscience into the care of veterans when President Obama signed legislation that will exacerbate this very problem. The “Comprehensive Addiction and Recovery Act of 2016” (“CARA”) contains provisions that will undoubtedly keep Tracy Gaudet, MD, and her merry band of integrative medicine aficionados at the VA busy for the next few years integrating even more quackery into veterans’ medical care.
CARA is intended to address the serious prescription drug abuse problem in the U.S. It provides grants for local communities dealing with drug abuse crises and for drug abuse programs, improves access to overdose reversal medication and medication-assisted treatment for drug addiction, and assists in training first responders, among other things. It also includes provisions related to pain management, such as development of best practices to treat pain. None of that is the problem.
Deep in the Act, almost at the end, is “Subtitle C – Complementary and Integrative Health,” which begins with “Expansion of research and education on and delivery of complementary and integrative health to veterans.” I am not sure who stuck this into the new law, but it is only tangentially related to addiction and recovery. It establishes the “Creating Options for Veterans’ Expedited Recovery” Commission or, in the acronym-rich language of government, “COVER.”
The COVER Commission is to examine the evidence-based therapy treatment models used by the VA for treating mental health conditions and “the potential benefits of incorporating complementary and integrative health treatments available in non-Department facilities.” This effort is to be directed at improving “wellness-based outcomes.” Authority to use “non-Department facilities” means that complementary and integrative services not provided in-house will be available to veterans, substantially expanding the opportunity to send them to questionable facilities.
And how is the VA to go about this? It is to examine the research on complementary and integrative health treatment therapies for mental health issues and identify what the benefit might be for including them. There’s a handy list of what Congress had in mind in the way of CIH (as it is now called) treatments: music therapy, equine therapy, training and caring for service dogs, yoga and meditation therapy (since when are yoga and meditation “therapies?”), outdoor sports therapy (same question), hyperbaric oxygen therapy, accelerated resolution therapy, art therapy, magnetic resonance therapy, and “other therapies the Commission determines appropriate.” As always, there’s a blend of more or less conventional stuff (art and music therapy, dog training) with pseudoscience (acupuncture), although I note that many of the standards didn’t make it, like reiki, healing touch, guided imagery, reflexology dietary supplements, and tai chi. Of course, they could fall into the catchall “other therapies” if the Commission so chooses.
I was intrigued by the inclusion of hyperbaric oxygen therapy. How could that possibly benefit mental health issues? That feat appears to be the result of a series of lobbying efforts by proponents of HBOT for PTSD, although clinical trials to date have not supported its use, nor do experts in HBOT think it’s effective. Behind this effort is a group of doctors of what appears to be the “brave maverick” variety, especially Dr. Paul Harch, who believes HBOT is an effective treatment for autism, if that tells you anything.
Accelerated resolution therapy (ART) is another new one. It is, according to the Substance Abuse and Mental Health Services Administration, (SAMSA),
a brief, exposure-based psychotherapy aimed at treating psychological trauma, depression, anxiety, phobias, obsessive–compulsive disorder, and substance use. The program is delivered in one to five, 60–75 minute sessions over 2 weeks. The program incorporates specific visualization techniques enhanced through the use of rapid eye movements (similar to the rapid eye movement stage of sleep) and a directive approach that reduces physical and emotional reactions to distressing memories and images stored in the brain.
SAMSA has concluded that ART is effective for reducing depression, improving personal resilience and self-concept, and reducing trauma and stress-related disorders, and is already in use in the military. The relationship, if any, between ART and the questionable Eye Movement Desensitization Reprocessing therapy is unclear. I am not sure why it is included as a CIH therapy, although that is the problem with the entire idea of CIH: There are no clear parameters and what is and isn’t CIH is too often in the eye of the beholder.
Magnetic resonance therapy is an off-label use of transcranial magnetic stimulation, which is FDA-approved for drug -resistant major depression. It is now the subject of a clinical trial for PTSD. Again, it is unclear why MRT is included in this category.
Eighteen months after the Commission’s first meeting, it is to issue a report on the VA’s evidence-based therapy model used for veterans with mental-health problems. As well, the report is to include
an examination of complementary and integrative health treatments [on the list] and the potential benefits of incorporating such treatments [in mental health therapy].
The VA must come up with an “action plan” for “improving wellness-based outcomes,” whatever that means. If the Commission recommends a particular CIH therapy and the VA doesn’t incorporate it, the VA has to justify its decision to Congress.
How all of this plays out likely hinges on who is appointed to the Commission, which is to be selected by various members of Congress and the President. CARA specifies that half must be veterans with a background in treating mental health and have experience working with the military and veteran population. They cannot have a financial interest in the CIH treatments reviewed. They may (but don’t have to) seek out guidance from outside groups, such as foundations, nonprofit groups, institutions of higher education and “other organizations,” leaving open the distinct possibility that CIH proponents could have a say in the outcome. If the Wayne Jonases of the world populate the Commission, we may well turn out to have another Whitehouse Commission on Complementary and Alternative Medicine on our hands.
Just what we need: more CAM research
CARA also says that, within 180 days of enactment (on July 22nd), the VA
shall develop a plan to expand materially and substantially the scope of the effectiveness of research and education on, and delivery and integration of, complementary and integrative health services into the health care services provided to veterans.
Expanding “the scope of the effectiveness of research” sounds a little like Tom Harkin’s desire that NCCAM “validate” CAM instead of finding it doesn’t work, if it makes sense at all. How do you expand the scope of the effectiveness of something?
In any event, all pretense of having anything whatsoever to do with mental health issues or drug abuse is abandoned and there is no list of treatments Congress favors. They mean all CAM/CIH for anything.
The plan must include research on the effectiveness of CIH health services, approaches to integrating CIH, and education and training for health care professionals in integrating CIH and “appropriate use of such services,” as well as “metrics and outcome measures to evaluate the effectiveness of integrating CIH.” In formulating the plan, the VA shall consult with, among others,
institutions of higher education, private research institutes, and individual researchers with extensive experience in [CIH] and the integration of [CIH] into delivery of health care [and] nationally recognized providers of complementary and integrative health.
Thus, CIH proponents will have an opportunity to influence the plan. No equal time for skeptics or SBM proponents is mandated.
Not only that, but the VA has to establish a pilot program at 15 VA medical centers to evaluate, among other things, whether CIH services are effective “in enhancing the quality of life of veterans” and in “increasing adherence to primary pain management and related services” and whether they “have an effect on the sense of well-being of veterans.” Note that this has nothing to do with effectiveness of the treatment per se, but basically looks at whether the CIH service makes the patient “feel better.” As we know, a quack treatment can do absolutely nothing objective for the patient’s condition, but the patient will perceive improvement where there is none.
And who is to provide these services?
Professionals or other instructors with appropriate training and expertise in [CIH] services who are employees of the Department or with whom the Department enters into an agreement to provide such services.
In other words, the VA can contract with chiropractors, acupuncturists, reiki healers or what-have-you to handle the pseudoscience.
As far as I can tell, CARA does not give the VA any money to do any of these things, although perhaps these mandates will be funded in the next budget.
According to David’s post, much of this is already happening, or is about to happen, at the VA anyway, as mandated by a memo from top brass. CARA puts the imprimatur of Congress on the whole enterprise and ensures it is enshrined into law, giving any dissenters little chance of stemming the tide.