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Caring for veterans who sustained injuries in the wars in Iraq and Afghanistan is one of the primary duties of the country’s system of veterans’ care. Today, because of advancements in medical technology and care on the battlefield, more veterans are surviving combat injuries than any previous generation. Many of these veterans will live their lives with complex injuries. Even more have sustained unseen injuries.

Like Vietnam veterans who only saw the impact of Agent Orange years after their service, today’s veterans may see lasting effects of the widespread use of burn pits to destroy all forms of waste. And the long-term impacts of the signature injuries of today’s wars—blast injuries such as Traumatic Bain Injury (TBI)—are still unknown. Without continued research, the country will be ill-prepared to handle the long-term effects of these injuries.

Meeting the demands of veterans of Iraq and Afghanistan will require investments in improving proven treatments and developing bold new treatments. Medical innovations coming out of the Deparments of Veterans Affairs (VA) and Defense (DoD) not only benefit our troops and veterans, but are soon adopted in the civilian medical community. Such innovations include improved technologies for the emergency treatment of hemorrhaging.

9.1: Improve Care for the Signature Injuries of the Wars in Iraq and Afghanistan
9.2: Expand Health Care Tracking and Research
9.3: Clarify and Support the Use of Service Dogs
9.4: Study and Field Innovative Health Care Treatments
9.5: Destigmatize the Use of Medical Marijuana

9.1: Improve Care for the Signature Injuries of the Wars in Iraq and Afghanistan

Post Traumatic Stress Disorder (PTSD) and blast injuries—including Traumatic Brain Injury and Tinnitus—are the most prevalent injuries of today’s veterans and service members. Today, almost 30 percent of the new veterans seeking care from the Department of Veterans Affairs (VA) have been diagnosed with PTSD. These numbers confirm the landmark RAND study of 2008 that revealed that nearly 20 percent of new veterans showed symptoms of PTSD or TBI. While more treatments are now available, the long-term impact of TBI is still unknown.

Tinnitus, defined as a ringing in the ears, is the injury most often seen in today’s veterans. Yet many VA centers still do not provide adequate treatment for the injury and few treatments have been developed to cure it or alleviate its debilitating symptoms.

Genitourinary (GU) injuries have also become increasingly common among veterans of Iraq and Afghanistan. Despite having access to treatment while in service, through the Department of Defense (DoD), veterans do not have access to reproductive services that give them a chance to start the family they hoped to have.

IAVA Recommendations:
I.
Research and develop medical treatment options to address Tinnitus that draw on the best resources of the government, private and nonprofit sectors.

II. Require that cognitive therapy be covered by TRICARE for veterans recovering from TBI. 

III. Maximize the effectiveness of the TBI Veterans Health Registry by requiring the DoD to share with the VA operational situation reports of all service members exposed to blasts and other causes of head and neck injury.

IV. Increase funding within the Department of Health and Human Services’ budget for TBI programs that will increase access to care, train local health providers and provide long-term community support.

V. Ensure that veterans with disabling genital injuries have access to the same reproductive services in the VA as in the DoD, including access to in vitro fertilization technology.

VI. Increase funding for non-profit groups that support veterans with the signature injuries of war, like IAVA, Fisher House, and Intrepid Fallen Heroes Fund.

9.2: Expand Health Care Tracking and Research

Many of the injuries that will confront today’s veterans are yet unknown. Previous generations saw new injuries caused by toxins or revealed by age, in some cases, 10, 20 or even 30 years after the end of the conflicts they fought in. The continued monitoring of health registries, and continued investment in research on the long-term health effects of the wars in Iraq and Afghanistan, will help the VA and other health care systems identify and address nascent problems and address them. For example, in 2008 RAND Corporation published a report on the invisible wounds of war that exposed the rates of invisible injuries, but since then there has been limited research to build upon this landmark study. Research must continue to support today’s veterans.

IAVA Recommendations:
I. 
Automatically enroll troops returning from a tour in Iraq or Afghanistan in the Gulf War Registry program, with the option to opt out. VA should launch a campaign to enroll veterans in the registry who have returned home prior to 2010.

II. Mandate and fund a comprehensive study investigating all potential long-term health effects from Iraq and Afghanistan veterans’ exposure to airborne hazards and open burn pits. 

III. Mandate that the VA partner with an independent research body, such as the National Academies of Science, to conduct a biennial review and provide a summary of research concerning the association between exposure to airborne hazards and open burn pits and diseases suspected to be associated with such exposure.

IV. Mandate a comprehensive study of the short and long-term effects of prophylactic medications such as the malaria drug Melfoquine (aka Larium) given to troops serving in Iraq and Afghanistan. The study should look at side effects, interactions with other medications, and the long-term effects of toxicity.

V. Develop an electronic system to track the purchasing and referrals of prosthetic and sensory aid devices.

VI. Ensure the proper funding for the Vision Center of Excellence (VCE) for the prevention, diagnosis, mitigation, treatment and rehabilitation of military eye injuries that was authorized by the 2008 National Defense Authorization Act (NDAA).

VII. Ensure proper funding and establish the Hearing Center of Excellence (HCE) and Limb Extremity Center of Excellence that were established in the 2009 NDAA.

VIII. Ensure dedicated program funding in the FY2016 budget for the Peer Reviewed Vision Trauma Program, including a line item budget request of $18 million for extramural research.

IX. Fund interdependent research to expand public knowledge of the injuries of today’s veterans, like RAND’s Invisible Wounds of War report.

9.3: Clarify and Support the Use of Service Dogs

Service dogs, trained to assist injured veterans with daily tasks, are quickly becoming a more widely recognized treatment alternative for veterans. IAVA members continue to rely on service dogs and find them to be essential to their recovery. Still, many misconceptions exist about service dogs, which can result in them being illegally barred from entering businesses and medical facilities, further isolating struggling veterans.

Today, the Department of Veterans Affairs (VA) provides benefits to veterans to care for a dog, as if it were a prosthetic device or other treatment that requires continued maintenance. Yet, many veterans are confused by the requirements of service dogs and there are no clear universal guidelines certifying service dogs. As a result, many veterans are seeking dogs without the proper training to fulfill their duties during the veteran’s recovery. Due to their widespread appeal and apparent benefit to veterans, the VA should invest in further research and outreach to clarify and expand the use of service dogs.

IAVA Recommendations:
I. 
The VA must partner with Assistance Dogs International accredited service dog agencies to educate VA staff and veterans on the availability of service dogs and the accompanying benefits.

II.The VA and the DoD must develop and improve their education and outreach efforts, both internally and externally, to educate providers on the new clinical guidelines, proper referral processes and the benefits available to veterans already using service and guide dogs.

III. The DoD and the VA must coordinate on common service and guide dog policies and benefits.

IV. The VA must improve its outreach and awareness efforts concerning the availability of service and guide dog benefits and clarify the application process.

V. The VA must start tracking how many veterans currently use medically prescribed service and guide dogs and how many veterans are referred to service and guide dogs agencies, as outlined in the newly published clinical guidelines for VA providers.

VI. Veterans using service dogs must be granted equal access to VA owned and controlled properties, as those veterans using guide dogs already have. This includes in-patient medical care. 

VII. Fund research to better define therapeutic and medical outcomes of veterans using service dogs.

VIII. Identify and fund best-in-class programs that train and support service dogs for veterans. IX. Launch a public awareness campaign educating non-VA medical facilities and businesses in areas with high concentrations of veterans about access for service dogs.

9.4: Study and Field Innovative Health Care Treatments

The Department of Veterans Affairs (VA) has long been a leader in innovative health care research, leading to many of the best practices in supporting veterans with service-connected injuries like amputated limbs or post-traumatic stress disorder (PTSD). With more veterans surviving traumatic injuries, the VA must continue its legacy of investing in innovative research to develop new methods to care for the long-term health needs of veterans of Iraq and Afghanistan.

Treatment options should include the full range of traditional and experimental options that have proven to be effective. Non-traditional approaches may break down some of the barriers veterans often face in seeking care, such as telemedicine, which can close the distance between a rural veteran and a VA facility or can bypass the stigma of seeking mental health care.

IAVA Recommendations:
I. 
Set outcome metrics for, identify and invest in best-practices for traditional, non-traditional and experimental treatments of invisible wounds, including meditation and acupuncture.

II. Fund research to explore innovative uses of telemedicine to provide care for rural and infirmed veterans who do not have easy access to medical facilities. 

III. Provide grants to innovative nonprofits, like UCLA’s Operation Mend and Massachusetts General’s HomeBase, that provide life-changing surgeries and medical services to severely wounded warriors at no cost.

IV. Continue investments in adaptive sports to support disabled veterans.

9.5: Destigmatize the Utilization of Medical Marijuana

The debate around legalizing marijuana for medical purposes is ending. Twenty-three states and the District of Columbia have legalized medical marijuana. And over 60 percent of IAVA survey respondents support the legalization of marijuana for medical use. IAVA members recovering from injuries have been extremely vocal in communicating the benefits for pain relief. While marijuana has been used to alleviate the symptoms of a number of symptoms and illnesses, the medical evidence is still insufficient to support the widespread use of medical marijuana, lacking information on safety, tolerability and efficacy. Researchers state that this is in large part due to challenges in researching the drug because of its status as a Schedule I Controlled Substance under federal law.

However, the evidence for medical benefits is promising. Patients using medical marijuana for various illnesses have seen the benefits firsthand and have become among the most vocal proponents for legalizing marijuana for medical use. Clearly more needs to be understood about the potential benefits of medical marijuana to treat a variety of symptoms and illnesses impacting veterans. In the meantime, veterans who are lawfully prescribed medical marijuana need the peace of mind that they can discuss their medical interventions with their Department of Veterans Affairs (VA) clinician without fear of prosecution.

IAVA Recommendations:
I. 
Ensure that veterans using lawfully prescribed medical marijuana, as determined by state law, are protected from federal prosecution.

II. Ensure veterans will not lose their VA benefits if they use legal medical marijuana. 

III. Fund research to assess the effectiveness of medical marijuana to treat veterans’ common injuries and to relieve pain.

IV. Allow and encourage a dialogue between patients and clinicians at the VA on their lawful (per state law) use of medical marijuana.