[Senate Hearing 108-261]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 108-261

                     LEGAL DRUGS, ILLEGAL PURPOSES:
                        THE ESCALATING ABUSE OF
                        PRESCRIPTION MEDICATIONS

=======================================================================

                                HEARING

                               before the

                              COMMITTEE ON
                          GOVERNMENTAL AFFAIRS
                          UNITED STATES SENATE


                      ONE HUNDRED EIGHTH CONGRESS

                             FIRST SESSION

                               __________

                             AUGUST 6, 2003

                               __________

                     FIELD HEARING IN BANGOR, MAINE

                               __________

      Printed for the use of the Committee on Governmental Affairs



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                   COMMITTEE ON GOVERNMENTAL AFFAIRS

                   SUSAN M. COLLINS, Maine, Chairman
TED STEVENS, Alaska                  JOSEPH I. LIEBERMAN, Connecticut
GEORGE V. VOINOVICH, Ohio            CARL LEVIN, Michigan
NORM COLEMAN, Minnesota              DANIEL K. AKAKA, Hawaii
ARLEN SPECTER, Pennsylvania          RICHARD J. DURBIN, Illinois
ROBERT F. BENNETT, Utah              THOMAS R. CARPER, Delaware
PETER G. FITZGERALD, Illinois        MARK DAYTON, Minnesota
JOHN E. SUNUNU, New Hampshire        FRANK LAUTENBERG, New Jersey
RICHARD C. SHELBY, Alabama           MARK PRYOR, Arkansas

           Michael D. Bopp, Staff Director and Chief Counsel
               David A. Kass, Chief Investigative Counsel
                 Bruce Kyle, Professional Staff Member
      Joyce A. Rechtschaffen, Minority Staff Director and Counsel
          Jason M. Yanussi, Minority Professional Staff Member
                      Amy B. Newhouse, Chief Clerk


                            C O N T E N T S

                                 ------                                
Opening statements:
                                                                   Page
    Senator Collins..............................................     1
    Senator Sununu...............................................     3

                               WITNESSES
                       Wednesday, August 6, 2003

Margaret Greenwald, M.D., Chief Medical Examiner, State of Maine.     5
Marcella H. Sorg, R.N., Ph.D., D-ABFA, Margaret Chase Smith 
  Center for Public Policy, University of Maine..................     7
John H. Burton, M.D., Medical Director, Maine Emergency Medical 
  Services, Research Director, Department of Emergency Medicine, 
  Maine Medical Center...........................................     9
Kimberly Johnson, Director, Maine Office of Substance Abuse......    11
Michael J. Chitwood, Chief of Police, Portland, Maine............    22
Lt. Michael Riggs, Washington County Sheriff's Department........    25
Jason Pease, Detective Sergeant, Criminal Investigations 
  Division, Lincoln County Sheriff's Department..................    27
Richard C. Dimond, M.D., Mount Desert Island Drug Task Force.....    34
Barbara Royal, Administrative Director, Open Door Recovery Center    37

                     Alphabetical List of Witnesses

Burton, John H., M.D.:
    Testimony....................................................     9
    Prepared Statement with attachments..........................    48
Chitwood, Michael J.:
    Testimony....................................................    22
    Prepared Statement...........................................    60
Dimond, Richard C., M.D.:
    Testimony....................................................    34
    Prepared Statement with an attachment........................    72
Greenwald, Margaret, M.D.:
    Testimony....................................................     5
    Prepared Statement...........................................    43
Johnson, Kimberly:
    Testimony....................................................    11
    Prepared Statement...........................................    56
Pease, Jason:
    Testimony....................................................    27
    Prepared Statement...........................................    70
Riggs, Lt. Michael:
    Testimony....................................................    25
    Prepared Statement...........................................    66
Royal, Barbara:
    Testimony....................................................    37
    Prepared Statement...........................................    77
Sorg, Marcella H., R.N., Ph.D., D-ABFA:
    Testimony....................................................     7
    Prepared Statement...........................................    45

                                Appendix

Charts submitted by Senator Collins..............................    82
Patricia Hickey, Bangor, Maine, prepared statement with 
  attachments....................................................    85
Kathryn T. Bernier, Bangor, Maine, prepared statement............    95
Ruth Blauer, Executive Director, Maine Association of Substance 
  Abuse Programs (MASAP), prepared statement with attachments....    97
Steven Gressitt, M.D., Acting Secretary, Maine Benzodiazepine 
  Study Group, prepared statement................................   106
Tammy Snyder, prepared statement.................................   107
Maine Drug-Related Mortality Patterns: 1997-2002, study by 
  Marcella H. Sorg, R.N., Ph.D., D-ABFA, Margaret Chase Smith 
  Center for Public Policy, University of Maine, Margaret 
  Greenwald, M.D., Maine Chief Medical Examiner, in cooperation 
  with the Maine Office of the Attorney General and Maine Office 
  of Substance Abuse, December 27, 2002..........................   114

 
                     LEGAL DRUGS, ILLEGAL PURPOSES:
                        THE ESCALATING ABUSE OF
                        PRESCRIPTION MEDICATIONS

                              ----------                              


                       WEDNESDAY, AUGUST 6, 2003

                                       U.S. Senate,
                         Committee on Governmental Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 10 a.m., in 
Council Chambers, City Hall, Bangor, Maine, Hon. Susan M. 
Collins, Chairman of the Committee, presiding.
    Present: Senators Collins and Sununu.

             OPENING STATEMENT OF CHAIRMAN COLLINS

    Chairman Collins. Good morning. The Committee will come to 
order. This morning the Senate Committee on Governmental 
Affairs is holding a field hearing on the diversion and abuse 
of prescription drugs.
    I am very pleased to welcome my colleague from New 
Hampshire and a Member of the Committee, Senator John Sununu, 
who has traveled to Bangor to join in this hearing this 
morning.
    Welcome to Maine, Senator. We are delighted to have you 
here.
    In 2001, deaths from prescription drug overdoses exceeded 
for the first time deaths from illegal drugs, an alarming trend 
that continues today.
    The number of Americans who regularly abuse prescription 
drugs was estimated at 1.6 million in 1998. Today that estimate 
is 9 million.
    It is tragically clear that prescription drugs, many as 
powerful and addictive as illicit drugs, increasingly are being 
diverted from legitimate use to illegal trafficking and abuse.
    This national problem has hit rural States particularly 
hard: Kentucky, West Virginia and North Carolina, for example, 
are all experiencing epidemics of prescription drug abuse, 
particularly in their rural regions.
    The Federal Drug Enforcement Administration reports that 
the diversion of prescription pain killers, oxycodone in 
particular, is an emerging threat in northern New Hampshire, a 
State already fighting a tide of heroin, cocaine, and other 
illegal drugs rolling in from the south.
    No State, however, has been hit harder than our State of 
Maine.
    As this chart shows,\1\ the number of accidental deaths in 
Maine from all drugs increased six-fold from 1997 to 2002, 
jumping from 19 to 126.
---------------------------------------------------------------------------
    \1\ The chart referred to appears in the Appendix on page 82.
---------------------------------------------------------------------------
    Prescription drugs were present in 60 percent of those 
deaths last year. As you can see, there has been an 
extraordinary increase.
    Also alarming, according to the 2002 Maine Youth Drug and 
Alcohol Survey, is that as many as 25 percent of the State's 
high school juniors and seniors abused prescription drugs.
    The category of prescription drugs most prevalent in this 
epidemic consists of opiate pain killers classified as Schedule 
II drugs. That is the Federal designation given to legal drugs 
with the greatest potential for abuse and addiction.
    The abuse of OxyContin in rural regions occurred swiftly. 
Now another Schedule II drug, methadone, is gaining the same 
degree of notoriety and it is showing up with growing frequency 
in autopsy reports.
    In Florida, methadone was present in 556 drug deaths last 
year, an increase of 56 percent over 2001; in North Carolina, 
methadone deaths rose 700 percent in 4 years; in Maine, 
methadone was the cause or contributing factor in 4 deaths in 
1997, but last year it was present in 46 deaths.
    The chart that we are displaying now shows the dominant 
role that methadone has played in this crisis.\2\ As you can 
see, a combination of drugs is most responsible for death, but 
right behind that is methadone.
---------------------------------------------------------------------------
    \2\ The chart referred to appears in the Appendix on page 83.
---------------------------------------------------------------------------
    The Federal Drug Abuse Warning Network reported that in 
2001 nearly 11,000 people turned up in emergency rooms after 
abusing methadone, almost double the number of such visits in 
1999.
    Methadone was developed in the late 1930's as a pain 
killer. It was only in the 1960's that its value in treating 
addiction was recognized.
    Used properly, methadone is a beneficial drug; but as the 
overdose numbers prove, it is a killer when used improperly.
    There are no national data on the amount of diverted 
methadone that originates from pain prescriptions compared to 
addiction treatment clinics. State-by-state anecdotal evidence 
suggests that treatment plans account from between one-third to 
one-half of the diversion.
    Although the majority of methadone overdoses may well come 
from pain prescriptions, the impact of treatment centers as a 
source is significant and troubling.
    The increase of more than 200 percent in methadone 
purchases by addiction clinics since 2000 is a powerful 
indicator of the overall increase in opiate addiction and of 
the amount of clinic methadone vulnerable to diversion.
    The dramatic increase in methadone abuse and deadly 
overdose coincides not only with the crush of new prescription 
opiate addicts needing treatment as well as with methadone's 
resurgence as a pain medication, but also with changes in the 
Federal regulation of addiction treatment clinics in 2001.
    Two significant developments occurred: The number of doses 
a clinic client could take home to avoid daily clinic visits 
was increased greatly.
    Under the new regulation a patient could take home as much 
as a 31-day supply versus a 6-day supply under the old rule.
    And second, a therapy of megadoses, doses many times 
greater than what had been standard, gained greater acceptance.
    But it is not just methadone and other Schedule II 
prescription drugs, such as oxycodone, that are doing the 
damage. In State after State, medical treatment and law 
enforcement authorities are reporting an ever expanding array 
of prescription drugs being diverted from their intended 
purposes to illegal purposes.
    These drugs may well be less notorious and subject to less 
scrutiny, and are increasingly being abused in combinations 
that result in addictions, dependency, and overdoses that are 
extremely difficult to treat.
    As we will hear today, the means by which these drugs are 
diverted range from petty theft to large-scale fraud and 
organized criminal activity.
    It is tragically ironic that while our streets are awash in 
diverted prescription medications, the under treatment of pain 
in legitimate patients remains a national problem.
    The American Medical Association reports that each year 
some 13 million Americans suffer from pain that could and 
should be relieved. A primary reason for this, according to the 
AMA, is that honest and caring physicians are increasingly 
reluctant to prescribe adequate pain relief, lest the drugs be 
diverted and lead to addiction and overdose and for fear that 
their prescription practices will be investigated.
    The diversion of prescription drugs must be brought under 
control, but measures to accomplish that goal cannot interfere 
with access to vital pain-relieving drugs by legitimate 
patients.
    Drug abuse has its greatest impact at the local level--on 
our streets, in our home, our schools, and in our workplaces.
    It is for that reason that much of the testimony we will 
hear this morning will be from those in the fields of medicine 
treatment and law enforcement who deal with this crisis on the 
front lines.
    The experiences of these Mainers are shared by their 
counterparts throughout the country, and I know that what this 
Committee learns today will be a great help as we proceed as a 
group to work together to tackle this nationwide and growing 
crisis.
    I would now like to turn to the distinguished senator from 
New Hampshire for any opening remarks that he may have; but 
again, let me say, Senator Sununu, how much we appreciate your 
being here today. I was delighted when you joined the 
Governmental Affairs Committee because of your well deserved 
reputation as a thoughtful and effective legislator. It is 
wonderful to have you here today.

              OPENING STATEMENT OF SENATOR SUNUNU

    Senator Sununu. Thank you, Chairman Collins. It is a 
pleasure to be here.
    One of the reasons I am so pleased to be a Member of the 
Governmental Affairs Committee, in addition to your great 
leadership, is the fact that we deal with so many and such a 
variety of complex issues.
    We deal with Homeland Security and National Security issues 
on the Committee, challenges with our information technology 
system, and in this case, no different, a complex problem that 
involves cooperative law enforcement at the State and Federal 
level, regulations we are dealing with, prescription drugs, and 
finding the best way to deal with the problem of illegal drugs 
or the abuse of the prescription drugs all over the country.
    It is a pleasure to be here to be able to take testimony 
from a number of panelists that we might not otherwise get a 
chance to hear from in Washington, a broad array of 
individuals, researchers, law enforcement representatives, and, 
of course, a lot of people who are involved in the treatment 
and the human services side of this problem.
    I think the importance of dealing with problems created by 
illegal trade in prescription drugs and other illegal drugs is 
indicated by the statistics that you outlined at the beginning 
of the hearing, in particular, the fact that overdose deaths 
from prescription drugs have surpassed that from other drugs in 
2001, and I think that is an alarm signal.
    It underscores the importance of getting our hands around 
this problem and discussing and identifying better ways to deal 
with it. This is something that is of great importance to all 
parts of the country but in particular, as Senator Collins 
outlined, to rural areas of the country. New Hampshire and 
Maine, I think, have seen very similar trends in the more rural 
parts of our States, and that brings the problem and challenge 
and the issues close to home for me.
    It probably means that the method that will be identified 
for dealing with this problem in our States or in certain parts 
of the rural parts of our States will be different than the way 
we might address or attack this kind of a law enforcement 
problem in more urban areas of the country.
    It is important that we hear from representatives from 
those parts of the country that are being affected, again, from 
the rural areas that oftentimes do not get the attention that 
we would like to see in Washington.
    It is important that we try to understand how to strike a 
good balance in regulation in providing assistance to the 
panelists who are represented here, that we provide right 
incentives to physicians--both to attract and monitor 
prescriptions--but also to deal with the important issue of 
providing pain relief to those individuals that need it so 
desperately to live more normal lives. And of course, with law 
enforcement to strike the right balance between being effective 
in dealing with the problem that does threaten security of our 
communities, but also being fair minded in the kinds of tools 
and power that is given to those law enforcement agencies.
    This is a great setting and a great forum for this kind of 
hearing. I very much look forward to hearing testimony from all 
of you. Thank you.
    Chairman Collins. Thank you very much, Senator Sununu.
    I am now pleased to welcome our first panel of witnesses 
today. They are each very distinguished in their fields and 
bring a great deal of expertise to our discussion this morning.
    Dr. Margaret Greenwald is the chief medical examiner for 
the State of Maine.
    With her is Marcella Sorg who has a Ph.D. and is a faculty 
member at the University of Maine School of Nursing. She is 
also director of the Interdisciplinary Training for Health Care 
for Rural Areas Program at the Margaret Chase Smith Center for 
Public Policy at the University of Maine.
    They are the co-authors of a very important report 
entitled, ``Maine Drug-Related Mortality Patterns, 1997-2002,'' 
which was published last summer.
    The statistical information that they gathered is used in 
my opening statement, and I want to credit them as being the 
source of that. It was really an eye-opening report, and we 
look forward to hearing your testimony.
    I am also very pleased to welcome Dr. John Burton. He is 
the medical director of the Maine Emergency Medical Services 
and research director of the Department of Emergency Medicine 
at Maine Medical Center in Portland.
    Dr. Burton is a very well known physician whom I have had 
the great pleasure of working with on a number of issues. 
Doctor, I very much appreciate your driving up from Portland to 
be with us today.
    He will provide us with a view of drug abuse and overdose 
from the perspective of an emergency room physician.
    Kimberly Johnson we are pleased to welcome as well. She is 
the director of the Maine Office of Substance Abuse.
    Her office provides leadership for the State's drug abuse 
prevention, intervention, and treatment program and collects 
important data on the problem of substance abuse.
    Thank you all for being here today.
    Dr. Greenwald, we will start with you.

    TESTIMONY OF MARGARET GREENWALD, M.D.,\1\ CHIEF MEDICAL 
                    EXAMINER, STATE OF MAINE

    Dr. Greenwald. Thank you very much. Chairman Collins and 
Senator Sununu, I want to thank you for the opportunity to 
appear before you on a topic which is of great concern to me as 
a public health professional and as the chief medical examiner 
for the State of Maine.
---------------------------------------------------------------------------
    \1\ The prepared statement of Dr. Greenwald appears in the Appendix 
on page 84.
---------------------------------------------------------------------------
    The abuse of prescription medications has been a major 
contributor to the amount of increase that we have seen in 
drug-related deaths in the State of Maine, and these deaths, of 
course, represent only a small part of the larger problem of 
substance abuse, which, as you mentioned, Chairman Collins, is 
rapidly becoming an epidemic in rural States.
    When I came to Maine in 1997, I was very pleased after 
being in a metropolitan area to see only 34 drug-related deaths 
in the entire State for the year of 1997.
    However, as the deaths began to gradually increase in the 
year 2000, it became clear that we were looking at a serious 
trend.
    Since my office is in the Office of the Attorney General, I 
spoke with Attorney General Rowe, and he felt that it would be 
important to provide a good statistical look at this problem.
    So Dr. Sorg and I, with the support of Kimberly Johnson 
from the Office of Substance Abuse and with a very important 
grant from the Maine Justice Assistance Council, were able to 
provide these statistics which we hoped would be used in just 
this way by policymakers and health care professionals, 
important to law enforcement, and also for the public to know 
what was happening in our State.
    A little bit of background of my office. The chief medical 
examiner investigates all unnatural or suspicious deaths for 
the State of Maine, so whenever there is a drug-related death 
that is identified, my office is immediately notified, and we 
actually direct the death investigation.
    As part of that investigation, we work directly with law 
enforcement and sometimes ask for more overall assistance from 
the Maine DEA or from the Maine State Police.
    All of those cases are autopsied in Augusta at our 
facility, the office of chief medical examiner, and we do blood 
analyses on all of the drug-related deaths.
    This includes not just the drugs which are illegal drugs 
which may cause the death, but we also end up seeing drugs 
which are legitimately prescribed to these patients and may be 
present in the blood.
    We do a toxicology screen that literally looks for hundreds 
of prescription drugs in the deaths that we are examining.
    When we determine a cause of death, which is one of the 
major points that we analyzed in this study, we are looking at 
all of these factors. We are looking at the circumstances of 
death, we look at the pathologic findings from the autopsy, and 
we also look at the drug tests that are there. We have to 
separate out those drugs which may be legitimately present from 
those which may have caused the death.
    In certain circumstances, however, because of the number of 
drugs and the levels that are present, as pathologists we 
cannot really say which particular drug caused the death.
    So you do see in the chart that you looked at earlier that 
there were a lot of deaths that were caused by polydrug 
overdoses, or multiple-drug overdoses, and that is a real 
problem in analyzing these deaths.
    So one of the things that Dr. Sorg and I did was to 
separate out two distinct different analysis. One was to 
actually analyze the deaths by cause of death, so which drugs 
were specifically indicated on the death certificate as causing 
the death.
    And then a separate and distinct analysis, which was to 
look at all of the drugs present in the toxicology which really 
gave us a picture of the drugs that were being used by the 
people in the State of Maine as well as those that were 
important in the death.
    The study, as you know, covered the 5 years from 1997 and 
actually ended in June 2002, but the chart that indicates the 
accidental and suicidal overdose, the numbers include final 
numbers from 2002; so it is actually an update from the study 
itself.\1\
---------------------------------------------------------------------------
    \1\ The study submitted for the Record appears in the Appendix on 
page 114.
---------------------------------------------------------------------------
    I think those numbers are probably some of the most 
important things that came out of the study. And as you noted, 
in 1997 we had 34 drug deaths and in 1998 and 1999 the deaths 
increased slightly.
    In 2000 we really had a major increase, and we began to see 
a two-time increase in the deaths since 1997; in 2001 there was 
a tripling of the drug deaths; and in 2002 the total numbers, 
there was a five-fold increase; and for the accidental 
overdoses it was, as you stated, a six-fold increase from 1997. 
So that is a very frightening figure.
    In 2003, as we look at those numbers which are not on the 
chart, there does seem to be a slight decrease. Since we are 
very early at the point of analyzing those figures, it is a 
little early to tell whether that will maintain throughout the 
year.
    But the major conclusions from the study are as follows: 
The increase in deaths is primarily due to accidental overdose; 
the majority of deaths are caused by prescription drugs; 
overall 62 percent of accidental deaths and 94 percent of 
suicides are caused by prescription drugs.
    The drug deaths affect all of Maine counties across the 
board. There is a slight difference in Cumberland County in 
that Cumberland County had 34 percent of the drug-related 
deaths as compared to 21 percent of the population. So that 
county actually did have a slightly more than would be expected 
by population numbers.
    And the demographics of the victims are essentially similar 
to what you see throughout Maine as a whole in terms of age and 
education.
    Some of the significant differences were that there were 14 
percent more males and there were 34 percent fewer who were 
married, which gives us some indication of what groups we need 
to look at in terms of the effects.
    Prescription drug abuse is a difficult problem, a 
multidisciplinary approach is important. I think that the 
Prescription Drug Monitoring Act is a good first step but it 
will need some good funding as will our law enforcement which 
requires a lot of time and effort to investigate these deaths. 
As you mentioned, the doctors who are trying to treat the pain 
patients and separate out those people who are going to be 
abusing the drugs will need research and education to help them 
identify those two groups. Thank you.
    Chairman Collins. Thank you very much, Doctor. Dr. Sorg.

TESTIMONY OF MARCELLA H. SORG,\2\ R.N., Ph.D., D-ABFA, MARGARET 
   CHASE SMITH CENTER FOR PUBLIC POLICY, UNIVERSITY OF MAINE

    Dr. Sorg. Chairman Collins and Senator Sununu, I am pleased 
to be here this morning to talk to you about this very 
important problem. I represent the Margaret Chase Smith Center 
for Public Policy.
---------------------------------------------------------------------------
    \2\ The prepared statement of Dr. Sorg appears in the Appendix on 
page 45.
---------------------------------------------------------------------------
    Our Drug and Alcohol Research Program has been working with 
Maine and New Hampshire and other rural States to try and 
address these issues of rural drug use and abuse.
    Our study of Maine mortality patterns includes 374 
decedents, as you said, between 1997 and 2002. The 
investigatory challenges for death investigations are very 
significant because many persons have multiple prescribers and 
pharmacies, and it is very difficult for investigators to find 
data on all the prescriptions for a death.
    Further, because people frequently fail to discard unused 
or old medications, current prescription status may not reveal 
complete information about the person's access to drugs even in 
their own home.
    Additionally, the drugs at the scene may or may not be 
related to the drugs found in the victim.
    Our study covered 5 years, but we have conducted more 
detailed studies in 2001 to find out about prescription status. 
That is where our statistics of 52 percent come from.
    We looked at 2001 and discovered that prescription status 
is available for almost all of the suicides but for only about 
half of the accidental deaths.
    With those who have prescription information, 88 percent of 
the suicide victims and 52 percent of the accident victims had 
a prescription for at least one drug that caused the death.
    So in other words, there is a subset of those for which we 
have prescription information, and of those, the accidents are 
less likely to have a legitimate prescription.
    Our examination of the 374 decedents from the 5-year period 
demonstrated that overdose victims are likely to have other 
medical problems.
    Fifty-five percent have a history of mental illness 
including depression, and about half--50 percent--have a 
history of drug abuse.
    The increase in drug deaths is largely a problem with drugs 
prescribed for pain, anxiety, and depression; and these are 
often found in combination.
    An overwhelming majority of deaths in Maine involve 
narcotics prescribed for pain and including, as you mentioned, 
methadone, oxycodone, fentanyl, and others.
    Narcotics, including heroin, are mentioned as cause of 
death in over 53 percent of the deaths. Prescription narcotics 
comprise 65 percent of the narcotics deaths.
    Narcotics are among the top five drugs found in the 
toxicology results when we look at those for both accidental 
and suicidal deaths, but the drugs are different.
    We tend to find methadone and heroin more in the accidents, 
and we tend to find oxycodone and propoxyphene in the suicides.
    Methadone is mentioned as a cause of death, alone or in 
combination, in 18 percent of all drug deaths, 26 percent of 
accidental drug deaths, and 33 percent of drug deaths caused by 
narcotics. It is found in the toxicology tests of about a 
quarter of all of our drug deaths.
    Methadone is often found with other narcotics, most 
frequently heroin and oxycodone. Most people who died from 
methadone toxicity were not involved in methadone maintenance 
programs.
    We looked at 2001 and found that 21 percent were being 
treated in a methadone maintenance clinic, 21 percent had a 
prescription from a pain clinic, and 58 percent had no 
documented prescription.
    There are wide variations in individual tolerance for 
methadone. Therapeutic and fatal doses overlap. Doses that are 
safe in one person are not safe in another.
    Individual tolerance can be reduced during substance abuse 
treatment or if a person is in jail, for example. And so the 
risks are enhanced after the tolerance is reduced.
    Oxycodone is a synthetic opiate. It has been marketed since 
1995 in the long-acting form OxyContin, and it is taken both 
orally and by injection among drug abusers. It is listed as the 
cause of death in 7 percent of death certificates, and we find 
it in 17 percent of toxicology.
    Benzodiazepines, which are prescribed for anxiety, are 
found in about a third, 32 percent, of all Maine drug death 
toxicology tests.
    Among the toxicology tests of all the drug victims, 71 
percent have one or more narcotics; 32 percent, one or more 
anti-anxiety drugs; and 37 percent, one or more 
antidepressants.
    Any attempt to address the problem and the risk they pose 
must be comprehensive. Clearly, electronic prescription 
monitoring systems are necessary, but experience with these 
programs nationally and internationally shows that real-time 
technologically-advanced systems are needed to provide 
immediate information to prescribers and pharmacies at the 
point of service.
    Research is needed to develop more sensitive and 
sophisticated practice guidelines with practitioners. Last, 
medical and law enforcement need expanded resources to handle 
the investigation needs.
    Thank you once again for the opportunity to bring this to 
your attention.
    Chairman Collins. Thank you very much, Dr. Sorg. Dr. 
Burton.

 TESTIMONY OF JOHN H. BURTON, M.D.,\1\ MEDICAL DIRECTOR, MAINE 
 EMERGENCY MEDICAL SERVICES, RESEARCH DIRECTOR, DEPARTMENT OF 
            EMERGENCY MEDICINE, MAINE MEDICAL CENTER

    Dr. Burton. Thank you very much. As you indicated, I am an 
emergency physician at Maine Medical Center in Portland, Maine, 
as well as the medical director for Maine Emergency Medical 
Services for the last 4 years.
---------------------------------------------------------------------------
    \1\ The prepared statement of Dr. Burton with attachments appears 
in the Appendix on page 48.
---------------------------------------------------------------------------
    Senator Sununu and Chairman Collins, about 15 months ago I 
was working in the emergency department, a usual Thursday, and 
a 16-year-old girl was brought into the emergency department at 
Maine Medical Center by her parents, and her story was that she 
was hooked on heroin and had been hooked on heroin for about 2 
weeks.
    Now, the way that she became hooked on heroin was 6 months 
earlier she started using OxyContin recreationally and she was 
purchasing that at her school.
    After about 5\1/2\ months she was unable to obtain her 
OxyContin and because she had a craving and a need, she 
progressed on to intravenous heroin abuse.
    She came into our emergency department, and we were able to 
connect her to rehabilitation. I do not know whether she was 
rehabilitated successfully, but as you know, the number of 
stories of rehabilitation are not too optimistic for that 
particular substance abuse.
    The second case I will tell you about was about 3 months 
after that. At a Saturday high school party in the greater 
Portland area there were three young men at the party, and as 
not uncommon for young males at a high school party, they were 
experimenting with alcohol, they were doing shots of beer.
    What was uncommon about it, though, was that they were 
mixing their alcohol with shots of methadone. How they obtained 
the methadone, I am not really sure, but they obtained the 
methadone and were mixing it in as a poly substance.
    About an hour later EMS providers were called to the scene. 
One of these individuals had problems breathing and was 
significantly impaired in terms of the level of conscious side 
effects of methadone.
    All three of these people were brought into our emergency 
department. One young man who was not breathing at the scene 
was treated with Naloxone. It was a close call for all of them. 
The other two, it was a pretty close call as well. Ultimately, 
after a multi-hour period, they were discharged.
    About 3 months following that there was a patient at 
another emergency department--one of my colleagues in western 
Maine relayed this--and this was a 23-year-old man who went to 
a house party. He was not an intravenous drug abuser, had no 
narcotic drug abuse history from what I was told by some of my 
colleagues, and he was able to obtain some methadone while he 
was at the party.
    Now, the connection at the party was that the host of the 
party had a parent who was a methadone clinic patient on high 
doses. She apparently had been stockpiling her methadone from 
her take-home liberties. It was either through her opportunity 
that she created or the opportunity that her son created that 
this other fellow was at the party and ended up taking 
methadone and at about 2 a.m. was found not breathing and 
unconscious on the party lawn.
    He was brought into the local emergency department and was 
pronounced dead upon his arrival at the hospital.
    Not all the patients end up being discharged.
    As has been indicated, the rise in observations that you 
see in emergency medical facilities, the emergency medical 
system, has really accelerated in the last 5 years. Based on 
activity it is probably about 4 percent per year for overdose 
patients.
    However, the drug-related and the narcotic-related activity 
is up on the order of 25 to 50 percent, particularly in the 
last year, 2002.
    I will tell you that that was quite motivating for myself, 
as well as the trauma surgeons at my hospital. It is a case 
that we have seen too often in the last year and a half.
    There were three individuals who crashed their car on the 
Maine Turnpike on a clear, bright sunny day at 11 o'clock on a 
Saturday. The story with them was they were all in the same 
vehicle, crashed the car into a bridge abutment, they were 
brought to the emergency department at Maine Medical Center. 
One of them had a fractured leg. It was a fairly high energy 
accident, so that the potential for severe injuries was great.
    They were lethargic; they had all been at a party. In 
talking with them, they had received their high-dose methadone 
at the clinic that morning, had taken a take-home dose either 
between two of them or all three of them--it was not clear to 
me whether two of them or all three of them--but they ingested 
their methadone in the parking lot, partied for an 
indeterminate amount of time and decided to drive home on the 
Maine Turnpike and then ultimately crashed the car.
    So I would indicate to you that the threat is not only to 
those who are using and abusing as we have seen before, 
methadone abuse, prescription drug abuse as you indicated, that 
then leads to other drugs in the narcotics, including heroin 
and methadone, and that threat is not only for those patients 
but also for those of us driving down the roads and working in 
those environments.
    The numbers currently support that for the year 2002 there 
is one life threatening overdose in the State of Maine from 
narcotics treated by emergency medical services every day.
    In the City of Portland that translates into one for every 
7 days, so once per week.
    So I thank you very much for inviting me and thank you.
    Chairman Collins. Thank you very much, Dr. Burton. Miss 
Johnson.

  TESTIMONY OF KIMBERLY JOHNSON,\1\ DIRECTOR, MAINE OFFICE OF 
                        SUBSTANCE ABUSE

    Ms. Johnson. Thank you. Chairman Collins, Senator Sununu, I 
am honored to be here with you today.
---------------------------------------------------------------------------
    \1\ The prepared statement of Ms. Johnson appears in the Appendix 
on page 56.
---------------------------------------------------------------------------
    The Office of Substance Abuse became aware of the growing 
increase in drug abuse early in the year 2000. At about the 
same time, law enforcement, particularly in Washington County, 
began noticing growth in trafficking across the Canadian border 
and experienced a growth in property crime due to abuse of 
OxyContin.
    If the medical community--particularly emergency rooms, law 
enforcement, poison control, and treatment field--had been 
collecting and sharing data at that time, we probably could 
have caught the problem at an earlier date and addressed it 
more effectively.
    As it was, there was not a comprehensive review of the data 
that existed until the Substance Abuse Services Commission 
released its report, ``OxyContin: Maine's Newest Epidemic,'' in 
January 2002, and I do not know if you have gotten a copy of 
that.
    This report collated local medical and law enforcement data 
and reviewed national data to gain a sense of the scope of the 
problem. The results were alarming.
    At all measures, prescription drug abuse has grown by 
epidemic proportions.
    As we currently found out in 2002, it became clear that 
there was a dramatic increase in drug overdose deaths chiefly 
in the City of Portland. The medical examiner's office began 
their review.
    At the same time, a research team from Yale University 
headed by Dr. Robert Heimer began a naturalistic study of drug 
abuse in Portland and in Washington County.
    While they have not yet published the data, preliminary 
data that the team has shared with us indicates that of the 238 
opiate users interviewed in Portland, 25 percent use heroin the 
most and the remainder used prescription narcotics the most.
    Interestingly, despite the attention that has been drawn to 
methadone, it does not appear to be a very popular drug among 
the interviewees in the Yale study.
    Twenty-five percent of the sample had used it at some point 
but it was not a preferred drug for most and was used primarily 
to stave off withdrawal symptoms.
    Of the methadone used, half was reported to be obtained for 
the treatment of pain and half had come from substance abuse 
treatment clinics.
    Historically there has been very little opiate abuse in 
Maine, and there has been very little methadone treatment.
    But by 2001 there was a strong demand for more treatment, 
and the client population at the existing programs had grown 
dramatically.
    In the span of 2 years the total methadone treatment 
population went from a stable population of 300 people to the 
current number, 1,600, and there is still unmet demand.
    We believe that the recent problems with diversion and 
abuse of methadone have to do with the rapid growth and need 
for treatment, as well as the relative naivete of the drug-
using population in Maine.
    Drug users did not seem to be aware of the pharmaceutical 
qualities of methadone and did not distinguish it from other 
opiates that they were abusing. They did not understand that it 
was slow acting as well as long acting. They attempted to 
inject it and they took repeated doses in order to get high.
    In August we reported our concerns with methadone abuse to 
the Center for Substance Abuse Treatment, which, as you know, 
is one of the centers in the Substance Abuse, Mental Health 
Services Authority under the Department of Health and Human 
Services.
    CSAT offered technical assistance and help developing and 
funding public education efforts. We found them to be very 
responsive to State needs and helpful regarding this issue.
    As CSAT heard from other States where methadone was being 
abused, they called together a working group of national 
experts and people from the various HHS offices to look at the 
etiology of the growth in methadone abuse and develop a 
response.
    The meetings which took place this spring--both Marcella 
and I attended--brought together data from a variety of sources 
and what became clear is that the overdose death issue is more 
complicated than you will find in the press reports.
    First of all, there has been a large increase in the use of 
methadone to treat pain, while the growth of methadone 
substance abuse treatment nationally has been moderate.
    The locales that seem to have developed methadone abuse 
problems are places where it has been a very relatively unknown 
drug, and there is an inexperienced drug-using population, just 
as we have seen in Maine.
    In my opinion, the switch of oversight of methadone 
treatment from the FDA to SAMHSA is coincidental to the growth 
in misuse of methadone.
    Growth of misuse of methadone has come from increased 
availability as it grows as a pain treatment and out of the 
desperation of drug addicts that cannot obtain their drug of 
choice or access appropriate treatment.
    Chairman Collins, you mentioned that there was a tragedy of 
under treatment of pain, and I will add to that that it is 
tragic how much we under treat addiction as well.
    Given our experience over the past 3 years, I would make a 
number of recommendations for addressing the problem of 
prescription drug abuse and preventing or providing early 
intervention to other emerging drug problems.
    I believe that having the ability to share data across 
various systems that deal with drug abuse is critical. I really 
believe that if OSA had had better data sooner, we could have 
stopped this problem before it became epidemic.
    We have begun working with the State Bureau of Health to 
follow a National Institute of Drug Abuse protocol for regular 
data sharing across systems. Nationally the DAWN network 
provides a similar tool, but it is only available to urban 
areas.
    CSAT's response to the methadone overdose issue is another 
good example of data sharing that could and should happen on a 
regular basis.
    Maine finally passed a bill creating an electronic 
prescription monitoring program, which you have already heard 
about today, and I would like to say I think it is a critical 
tool and we appreciate the Department of Justice having funding 
for that and hope we can benefit.
    I also think that medical providers must receive better 
training in addictions. Most providers do not even ask 
questions about alcohol consumption, let alone drug use. They 
are not adept at recognizing the signs of substance abuse and 
do not know what to do when they have a patient with addictive 
disorders.
    Many are very misinformed about appropriate treatment 
protocol.
    Providers that treat pain should learn how to appropriately 
withdraw a person who has become physically dependent on 
prescription narcotics. Many of the people now treated in 
addiction clinics began as legitimate pain patients.
    First of all, medical personnel rarely screen for 
susceptibility to addictive disorders prior to prescribing 
potentially addictive medications.
    Second, they often do not handle a patient's growing 
tolerance to a medication well, interpreting their tolerance as 
drug seeking or addictive behavior.
    Finally, medical staff need to learn how to appropriately 
withdraw patients from medications to which they have developed 
tolerance and physical dependence, which is not necessarily 
addiction.
    For many patients, their addictive behavior began when 
their need for pain medication was over, but their 
uncomfortable, even painful withdrawal from their prescribed 
medication led them to seek other sources of relief which 
eventually led to the cycle of addiction that we all know of.
    I am concerned with current marketing practices. While 
Purdue Pharma has been chastised for its aggressive marketing 
practices, I am less concerned about marketing to prescribers 
who should know better through training and experience and more 
concerned about direct to consumer marketing.
    Scheduled drugs are not marketed directly to consumers, but 
everything else is. When I sit and watch TV with my teenage 
daughter, I am amazed to see the quantity of prescription drugs 
advertised. They all have the same format, which is to make you 
think that symptoms of indigestion, PMS, or sadness may in fact 
be a serious disease for which medication is necessary.
    In my opinion, these ads have created a sense of urgency 
about every medical symptom and have presented the solution as 
taking a pill. The pills are attractive, the side effects are 
described as mild, and the need as serious.
    Our current generation of adolescents was raised watching 
these and at the same time they have been watching ads about 
the dangers of illegal drugs.
    I do not think it should come as any surprise that they 
perceive pharmaceuticals as a safe and effective high. The 
industry practice is relatively new and only predates the 
growth in abuse of prescription drugs by a few years, which 
helps to confirm the connection in my mind.
    We cannot restrict type and placement of commercial speech 
and things that we talk about, but I believe that we should 
address this new practice by pharmaceutical companies as it has 
created the social climate that has made prescription drug 
abuse inevitable.
    Thank you.
    Chairman Collins. Thank you, Miss Johnson.
    Let me start with a point that you were getting to at the 
end of your statement and that is, do you think we need an 
educational campaign to alert people to the dangers of 
prescription drugs?
    Is it your belief that individuals who would never think of 
trying heroin or cocaine somehow think that it is safe to 
experiment with prescription drugs which may be equally 
addictive and equally powerful?
    Is there a disconnect in the public's mind in looking at 
prescription drugs versus illegal drugs?
    Ms. Johnson. I think absolutely there is. It is not just 
drug abusers that we are talking about. If you think about the 
general population, maybe people that you know, I cannot tell 
you how many times--I am terrified of flying--I can count how 
many times people have said, well, you want a Xanax? I have a 
Valium. It is a very common practice to share your medication. 
I think that people do not even think of that as abuse.
    I think parents, in particular, do not think about what is 
in their medicine cabinet. They are pretty careful about 
watching the alcohol and watching for symptoms of illegal 
drugs, but parents, grandparents, do not think about the pain 
medication that might be 2 years old sitting in the medicine 
cabinet, and I have heard anecdotes of kids going to parties 
and they all bring something from a family medicine cabinet and 
dump it into a bowl. That is the evening's entertainment, 
popping pills.
    I think maybe we need more public education about the risks 
and more professional education about the risks of prescription 
drugs.
    Chairman Collins. Dr. Greenwald, you made a very important 
point and that is the study that you and Dr. Sorg conducted 
showed that the abuse of prescription drugs was a problem in 
every single county in Maine. It was not confined to Portland, 
although you said that Cumberland County was even higher than 
proportionate of population, but you found overdose deaths in 
every county; is that correct?
    Dr. Greenwald. That is correct.
    Chairman Collins. Did you find that particular drugs were 
in particular counties? Were there any patterns as far as the 
kind of abuse that is occurring in rural versus urban areas of 
the State?
    Dr. Greenwald. Actually, when we looked at the drugs, they 
seemed to be fairly evenly distributed throughout; and 
methadone, heroin, and oxycodone were really in all of the 
counties in varying numbers.
    Chairman Collins. Dr. Sorg, your study demonstrates just 
how rapidly the drug problem in Maine has grown. If you look at 
the chart,\1\ it is really an exponential growth in the abuse 
and consequent death from prescription drug overdoses.
---------------------------------------------------------------------------
    \1\ The chart referred to appears in the Appendix on page 82.
---------------------------------------------------------------------------
    One of the facts in the report that surprised me the most 
was that Maine's problem appears to be more severe than in 
other parts of New England. For example, Maine's death rate per 
100,000 from opiate abuse has almost quadrupled since 1997, 
while Connecticut, for example, has remained basically flat.
    Why do you think our State has been hit so hard by this 
epidemic?
    Dr. Sorg. First of all, I think it is something that is 
characteristic of rural areas right now, and it is not just the 
State of Maine that has experienced this.
    Second, I think that--as Ms. Johnson mentioned--it is a 
factor with respect to the experience of the users.
    In Connecticut, for example, there has been a lot of 
experience with opiates going back 30 years. In Maine, not so. 
It is a naive population. The population does not have a lot of 
experience.
    The other part I would like to mention is that it may be 
related to economic conditions and a way of making money. In 
some cases that may have increased due to the marketing of 
prescription drugs.
    Chairman Collins. Dr. Burton, you have estimated that up to 
75 percent of the drug-related emergency room encounters that 
you have seen involve methadone.
    Could you explain to us why it is so easy to overdose on 
methadone so that we have a greater understanding.
    Dr. Burton. I think a number of cases are where I see 
people who are not used to using narcotics. They think it is 
like popping a pill.
    One of the problems is that methadone is frequently 
dispensed in the Portland area as a liquid formula, so it is 
real hard to get a sense of how much is more than enough. It is 
not just a pill.
    So instead of popping a small dose in a pill that probably 
would not hurt anybody, though that is still not a good idea, 
they end up taking this unknown quantity of liquid and they 
come in unconscious. These are people who are not used to this.
    Even though the people who are not used to using this drug, 
for some reason--take interest in it, the availability, the 
mystique, or whatever it is--they have become addicted.
    Chairman Collins. Is it slow acting also so that the person 
taking it may take more to try to get a more powerful high and 
not understanding it is going to depress breathing? Is that a 
factor?
    Dr. Burton. That is certainly a factor. If they start 
taking extra doses because they did not get high from the last 
one, it is slow acting.
    What is kind of unique about the motor vehicle crashes that 
we have seen as trauma surgeons and emergency physicians at my 
hospital is that we have seen a tremendous number of methadone-
impaired patients coming in from motor vehicle crashes where 
they have been driving.
    That is not supposed to happen because the drug takes a 
while to kick in, and so by the time they have driven home, the 
drug kicks in, particularly for someone who is taking a 
standard dose may lead to a car crash.
    So it makes many of us wonder whether the crashes that we 
are seeing are again because of people using extraordinary high 
doses in excess of 200 milligrams--it is very common in high 
doses--if that creates more opportunity for impairment or if 
that just creates more opportunity to divert it to people who 
then utilize it and drive impaired by it.
    Chairman Collins. Thank you.
    Dr. Sorg, I want to go back to a statement that you made in 
your testimony and make sure that I understand it.
    You said in looking at individuals who had died from 
methadone toxicity that 21 percent were being treated in a 
methadone maintenance clinic, 21 percent had a prescription 
from a pain clinic, and 58 percent had no documented 
prescription.
    Does that mean that those 58 percent obviously got 
methadone from illegal sources? I just want to make sure I 
understand what you are saying.
    Dr. Sorg. That is our understanding, too. The sample size 
is small, so the numbers may not be precise.
    But certainly we do call the few clinic that are around and 
make sure that they are not patients with those clinics. We can 
rule that out.
    We cannot rule out that somebody got it from a clinic out 
of State. But other than that, the 58 percent are probably 
obtaining it from illegal sources.
    Chairman Collins. Dr. Burton, based on your experience, do 
you believe that most of the methadone that has been diverted 
is coming from prescriptions for pain relief or from addiction 
clinics?
    Dr. Burton. I would say--I would be careful passing an 
opinion on that. We have seen a lot of both.
    There has certainly been a lot of physicians who prescribe 
methadone to control pain, it is fairly common. Actually, we 
have seen those patients.
    However, in the last 2 years in my personal experience the 
numbers seem much more weighted toward those being treated from 
a methadone clinic, I think because they are given those higher 
doses and large quantities.
    Chairman Collins. Let me follow up with you on the issue of 
high-dose methadone treatment.
    You identified two problems in your statement, first, that 
it may lead to an increased risk of diversion and second, that 
it may lead to greater side effects, you described the 
automobile accident, for example, as an indication of that.
    In your personal view do you believe that high-dose 
methadone treatment needs to be more closely regulated? Did the 
Federal Government make a mistake in expanding both the amount 
that a patient could take home from a clinic from 6 days to 31 
days--in some cases--but also in approving megadoses that are 
getting wider acceptance but not used to be a standard 
treatment?
    Dr. Burton. I am an emergency physician, I am not a 
specialist in drug treatment.
    However, I can tell you that I have read a large number of 
studies that seem to prove the wisdom of high-dose methadone.
    What those studies do is they look at the success of 
patients in the programs when you drive their dosing to higher 
levels and that keeps them in the program.
    So those individual patients do well. I would ask if anyone 
has ever seen a study that has simultaneously been described, 
during the time period studied, diversion rates, accident 
rates, emergency department visits, any marker that you could 
show of diversion.
    You are not going to publish that in the study. You only 
want to show a patient's success and how it did for them.
    So my point is that I believe that in those studies and in 
that data there has been a large story that is not told. And I 
believe that part of that story is that it creates tremendous 
opportunity for diversion, but also if you couple that with a 
take-home program of 1 week or 1 month at high dose, it is a 
tremendous opportunity to stock up methadone. Many of these 
patients have stockup up for a rainy day for when they are 
feeling really bad or down, so they are just keeping a stash.
    So my personal opinion is yes, it needs to be reviewed, it 
needs to be revisited with a particular emphasis on what is the 
effect to the community.
    Chairman Collins. Dr. Greenwald, you said in your 
statement--and you are absolutely right--that if we are going 
to tackle this problem, we need a multi-pronged approach.
    My last question to the panel before I turn to Senator 
Sununu is to ask each of you: If you had one recommendation for 
the Committee on what needs to be done to make a difference in 
tackling this terrible epidemic of drug abuse, what would your 
recommendation be?
    And I realize this may be something at the State level, 
Federal level, locally, etc., but whatever it is. Dr. 
Greenwald.
    Dr. Greenwald. Actually, I think my recommendation would 
cover many of those different levels. One of the things that I 
see as the chief medical examiner when patients come to our 
office is that many of the patients come in with literally bags 
of prescription drugs.
    So I think that a point that Dr. Sorg made is that we need 
to have research in good pain management and education for the 
physicians prescribing so that they can work with their pain 
patients in realizing how to best treat the patients without 
ending up having the patients have access to large numbers of 
different medications.
    Chairman Collins. Thank you. Dr. Sorg.
    Dr. Sorg. I would agree with Dr. Greenwald, of course, but 
I also think that information for the providers that might come 
from a prescription monitoring program is important, and I 
think that information needs to be available at the point of 
writing the prescription.
    It needs to be a real-time system and such a system is much 
more expensive. I think the decisionmaking process is part of 
the key.
    Chairman Collins. Thank you. Dr. Burton.
    Dr. Burton. I have to think about in the last 7 months, 
there has been a number of us who believe that the numbers are 
down. I do not have data showing that, it is not zero.
    I had two heroin patients in the last 3 days in the 
emergency department. One of these was a young woman that was 
dropped off at the door.
    But I think the numbers are down and I think the reason why 
the numbers are down, if indeed they are, is largely to the 
efforts of people like Dr. Sorg, Dr. Greenwald, and Ms. Johnson 
and their efforts to include the communication and the 
willingness of the law enforcement community to get into 
discussion and also the addiction community, the owners of 
methadone clinics, and the representatives of the end users who 
sit at the same table and have a discussion and open the doors 
that when we see diversion occur that it is OK to then contact 
someone in these other areas to notify them of this so we can 
make sure that we are monitoring these practices and 
activities.
    The problem is it is a piece of that pie and each group 
would have a different piece of that pie.
    My one wish would be that we would have some process that 
would enable us to indicate when we see these patients--
particularly allow us to do that on the medical side without 
getting sued or violating the patients' rights, which are 
important, but there are elements that we could put in there.
    Chairman Collins. Thank you. Ms. Johnson.
    Ms. Johnson. I think my colleagues have said it all. Better 
information, the ability to share information, and that 
includes a prescription monitoring program that includes all of 
the data that we all collect and sharing that, and better 
physician provider education and public education.
    Chairman Collins. Thank you very much. Senator Sununu.
    Senator Sununu. Thank you, Chairman Collins.
    Dr. Greenwald, I know that when you go into a research 
project you do your utmost to not have any preconceived ideas 
of how the data might come out, what it might show, but is 
there anything in particular that you can point to in your 
study that you found surprising or counterintuitive?
    Dr. Greenwald. I do not know if it was counterintuitive. We 
knew that we were seeing increases in heroin deaths, but I 
think that the thing that surprised me the most, perhaps 
because of publicity that was around methadone at the time that 
we did the study, but was the numbers of actual heroin deaths 
in the State of Maine. I did not expect to see those numbers.
    Senator Sununu. And you mentioned that the preliminary 
data--I guess about a half a year's data now--2003 shows a 
decline?
    How great a decline and what are the reasons?
    Dr. Greenwald. Well, I can give you some ideas on that. We 
had 126 accidental overdoses in 2002, and it looks like the 
numbers will be down to about 100 if the numbers hold in 2003.
    Again, we are still very early in looking at those numbers. 
I think that all of the issues that were mentioned, 
particularly the communication and attention and scrutiny by 
the clinics and by law enforcement, I definitely have seen a 
difference in our deaths; and when investigation is performed, 
we are hearing much earlier about the concept of diversion in 
the deaths, so I think that law enforcement is looking at these 
much more closely now.
    Senator Sununu. Dr. Burton, are the admittance numbers 
anecdotal evidence comporting with those numbers? In other 
words, are you seeing a modest decline in numbers of 
admittance?
    Dr. Burton. I have not seen any numbers from 2003 either 
from health care emergency medical services or in hospital 
admission data.
    Senator Sununu. Are numbers tracked by emergency room 
services? Are they statewide or regionally?
    Dr. Burton. Part of the problem is that there has been no 
way to track this. One of the things that I point out to people 
is that if your daughter--I do not know that you have a 
daughter--if she was at a party and someone shot her in the 
foot just playing around and she was brought into the emergency 
department, I would have to report that. It is required of me 
to report.
    Senator Sununu. Required by the State----
    Dr. Burton. By the State. However, if someone decided to 
give her a large dose of methadone and she became blue and was 
brought in by EMS providers, I cannot report that and to the 
contrary I would be discouraged because of confidentiality 
surrounding her rights as an individual patient.
    In young people, when you see a case like that you cannot 
engage--or you have to seek an attorney's opinion before you 
can either get it into a database somewhere or contact a law 
enforcement official just to let them know this happened and 
not identify the patient.
    We do not have any means in the health care system at the 
hospital level to track it.
    Senator Sununu. Ms. Johnson, you mentioned the importance 
of data sharing and information sharing.
    Have you seen these same issues of confidentiality would 
cause problems and improving a system for data sharing?
    Ms. Johnson. It is very difficult to share data or 
information on an individual client. It really is not that 
difficult to share aggregate data.
    Some of the data is missing. We are actually working with 
the Maine Medical Center and Eastern Maine Medical Center in 
developing a system that collects infectious disease data, but 
we are still looking at adding drug abuse data to that system. 
So missing data is part of the issue.
    Senator Sununu. Dr. Burton, did those same obstacles make 
it difficult to identify--to establish firm statistics on the 
number of admittances who were driving under the influence, the 
traffic accidents for 2000, or fatalities due to the 
prescription drug abuse?
    Dr. Burton. I would say yes and no. Yes, the same issues 
apply with patient confidentiality. So then to communicate that 
to law enforcement or a database is problematic.
    On the other hand, no because we have already thought 
through that about 10 years ago and there was a number of ways 
and some tracking is to follow that data. There are probably 
ways we can query that because they have worked through that.
    Senator Sununu. Ms. Johnson, with the opportunity to 
provide assistance in a clinic using greater doses, so-called 
megadoses and greater take-home periods from 6 to 31 days, to 
what extent is that being utilized or taken advantage of? And 
to what extent have you seen that exacerbated?
    Ms. Johnson. Current practice in addiction treatment with 
methadone is similar to the current practice in terms of pain 
treatment where we have learned that over the years we have 
under treated it.
    The dosages that were considered acceptable in years past 
really are considered now to be under treatment for those 
patients.
    I know the dosage issue is controversial in Maine, but 
nationally it is pretty much accepted practice. We have a 
handful of a very small number of patients in Maine who have 
very high doses, over 400 milligrams.
    I get a list of some of those people. So I am less 
concerned about that.
    The take-home--the ability to take home more than a week's 
worth of medication--is really an issue to address how this 
interferes with people's abilities to live a normal life.
    That part of treatment is trying to get people to become 
responsible and lead normal productive lives like the rest of 
us. And having to go to pick up your medication every week 
interferes with that, particularly in a rural State.
    We have people up in Calais driving to Portland 5 hours 
away to get medication. Some of them are doing that daily now.
    People who have those kinds of long take-home privileges 
are people that have been in treatment for a long time and they 
are given strong education of their ability to have that 
responsibility.
    There are eight criteria that they have to meet in order to 
have that.
    What I do think about the problem in Maine is that in 
Portland the two clinics were only open 6 days a week, so 
everyone got one take-home dose a week.
    It was really at the clinic's recommendation and we are 
changing the State regulation to reflect that, that it is going 
to be required to be open 7 days a week so that you do not come 
in Wednesday as a new patient and then Saturday get a separate 
dose to take home.
    My conversations with the Maine DEA have indicated that the 
issue of liquid methadone, the clinic methadone, was primarily 
single dose and it was probably found in those patients 
relatively early on in their treatment.
    They should not have had take-home privileges but did 
because the clinics were open 6 days a week. I suspect that 
since that change last summer, that has had an effect on the 
reduction and some of the problems that we have seen.
    Senator Sununu. What percentage of clients are taking 
medication--are given the 31-day--I guess the 31-day privilege 
is new?
    Ms. Johnson. Very few. Actually, my office has to approve 
it. There are, I think, fewer than 20 patients in the State 
that have privileges that are that long. Most are under 2 
weeks, so except for that handful, they are all under 2 weeks 
and most are even shorter than that.
    Senator Sununu. Thank you very much.
    Chairman Collins. Thank you, Senator Sununu. I want to 
thank this panel very much for being with us this morning. We 
will put your full statements that you provided into the 
hearing record. Thank you very much.
    I would now like to call forward our second panel where we 
will get the views of law enforcement officers who see the drug 
problems from several angles. They are on the front lines of 
the battle against drug traffickers, they deal with the 
explosion in property crime and violence that results from drug 
dealing and abuse, and they are often first on the scene when 
the abuse turns to overdose.
    We are very fortunate today to have three highly 
experienced officers with perspectives that range from Maine's 
largest city to some of the most rural counties.
    Portland Police Chief Michael Chitwood is a highly 
decorated police officer with 38 years of experience. He has 
dealt with the preponderance of methadone overdoses in Maine's 
largest city. We very much appreciate his driving up from 
Portland to be with us today.
    Lieutenant Michael Riggs of the Washington County Sheriff's 
Department. He's one of the most experienced drug investigators 
in Maine.
    His county in easternmost Maine is among the first rural 
regions in the Nation to experience widespread prescription 
drug abuse and it remains, unfortunately, one of the hardest 
hit.
    Detective Sergeant Jason Pease of the Lincoln County 
Sheriff's Department has lead successful investigations in a 
variety of drug diversion schemes including large-scale doctor 
shopping rings.
    His county, in the State's mid-coast region, has faced both 
the rural prescription drug phenomenon as well as the urban 
illicit drug trade.
    We very much appreciate the three of you being here.
    Before I call on Chief Chitwood, I just want to let 
everyone know, because I do not think I made the point clearly 
to the previous panel, that according to the most recent 
available data from the U.S. Department of Health and Human 
Services, Maine substance abuse admissions rates for all 
opiates other than heroin is not only more than six times the 
national average, but it is the highest in the Nation. So we 
really do have a serious problem that we are dealing with.
    Chief Chitwood, thank you for being here today, and I will 
start with you.

TESTIMONY OF MICHAEL J. CHITWOOD,\1\ CHIEF OF POLICE, PORTLAND, 
                             MAINE

    Chief Chitwood. Thank you, Chairman Collins and Senator 
Sununu.
---------------------------------------------------------------------------
    \1\ The prepared statement of Chief Chitwood appears in the 
Appendix on page 60.
---------------------------------------------------------------------------
    I would like to thank you for allowing me this opportunity 
to be here. I am here to discuss an issue that I have seen grow 
into epidemic proportions over the last several years.
    Methadone abuse is affecting people in our communities in 
every county of the State. Statistics are dire and it is 
imperative that steps are taken to combat this rapidly growing 
problem.
    Over the last 5 years, as you have already heard statistics 
from other groups, there has been a four-fold increase in drug 
deaths in Maine.
    In the City of Portland and Cumberland County, methadone 
was a causation factor in at least 30 deaths in 2003 according 
to the State medical examiner. This rise in deaths is due 
mainly to accidental overdoses.
    What I find most deplorable and tragic is the lives that 
have been destroyed on methadone. Over the past several months 
I have received numerous calls and letters from people who have 
lost loved ones due to methadone and who are desperate for 
help.
    A woman who is present in the room today, Linda Nash, 
called me recently and shared with me a horrific story of how 
she lost her 21-year-old daughter Kelly due to methadone 
overdose.
    Her daughter Kelly was seeking treatment for heroin 
addiction, and her mother watched as her methadone doses were 
increased steadily by a local clinic from 40 to 110 to 210 
milligrams of methadone daily.
    Concerned, her mother tried to speak with someone at the 
clinic but she felt as though her distress fell on deaf ears. 
At this high dosage her daughter became sluggish and ill. She 
fell asleep at the wheel of the car and was involved in several 
accidents.
    The mother described Kelly as so constantly inebriated by 
methadone that she forgot when she took her last dosage until 
she took too much and died. Kelly left behind a baby boy.
    What I would like to share is I would like to give a quick 
overview of how easy it is to hoard methadone from the clinics 
in the greater Portland area.
    Here are 13 vials of take-home methadone that were 
prescribed to a 22-year-old who was an admitted heroin addict 
and while on the methadone program was making weekly trips to 
Massachusetts for his heroin.
    The scripts were from one of our local clinics, The 
Discovery House, in South Portland, Maine. He was entrusted 
with take-home doses of methadone, it was hoarded and packaged 
for sale.
    He sold his take-home methadone to support his heroin 
habit. The methadone in this case was seized by a tip by an 
informant and a search of his home.
    The second vial is a vial that the label has been taken 
off. Again, it is 330 milligrams of methadone prescribed by 
another local clinic, CAP Quality Care.
    Both of these cases have been settled, and that is why I am 
allowed to bring these before you--adjudicated, I am sorry.
    In this particular case, George Higgins was recently 
sentenced for supplying or furnishing methadone to a young man 
who subsequently died as a result of the methadone that was 
supplied to him. Higgins was again on take-home methadone and 
during the course of a party, Higgins gave this dosage to a 
gentleman who died on August 31, 2002.
    Again, another example of how easy it is. There are 
probably hundreds of examples statewide.
    I have heard multiple tragic stories like this going on and 
feel helpless because we have two for-profit methadone clinics 
dispensing this drug without, in my opinion, adequate 
oversight.
    The very nature of for-profit clinics creates incentives to 
keep people on methadone or stretch out the amount of time they 
are taking it and being weaned from it.
    Furthermore, the clinics are sending people home with 
methadone and minimal counseling and education. Even someone 
with a criminal history can be allowed take-home methadone. 
Granted, not all methadone users have a criminal history, but 
any social deviant with a history of breaking laws and using 
illicit drugs should not be entrusted to handle a powerful drug 
responsibly.
    This is not to say that criminals who are addicted do not 
deserve the treatment, they absolutely do. However, the 
treatment should be administered at a clinic under close 
supervision. The result of this current ``drive-through-
window'' approach to methadone is that the drug is being 
diverted, misused, and causing people to die at alarming rates.
    Based on my experience there is no doubt in my mind that 
State and Federal regulations pertaining to dispensation of 
methadone must be strengthened. The Federal guidelines, which 
were designed to make methadone treatment more accessible--for 
example, take-home doses--have created a crisis.
    People are taking the methadone home but in too many cases 
they are selling it or letting their friends take it. As you 
know, methadone does not create a high like other drugs. The 
result is that you have people mixing alcohol and other drugs 
at a party and somebody gives them some methadone. Thinking 
that they are going to get high as with other drugs, they take 
it and end up either dead or unconscious.
    Currently the State Office of Substance Abuse, in my 
opinion, is not doing enough to monitor, evaluate, or intervene 
on this deadly trend. In fact, if anything, I feel that they 
have contributed to the problem by spending $24,000 on radio 
ads promoting methadone use like it is the cure-all, like it is 
going to cure opiate addiction. These funds could have been 
better used through education rehabilitation and enforcement.
    Another way that methadone is being used is through 
prescription drug diversion. The methadone being abused appears 
to be tablets prescribed for pain. These are sold or sometimes 
given to addicts by people who have stolen from patients, in 
some cases, by patients themselves. Addicts either swallow the 
tablets or grind them into powder that can be inhaled or turned 
into liquid and injected.
    Even though this is a lesser problem in Maine, it is 
something that we need to watch carefully. I am hopeful that 
the prescription drug monitoring bill that was passed during 
the last legislative session will be a useful tool for getting 
health care providers informed and educated regarding patients 
with drug-seeking behaviors.
    While policy changes are imperative, they should be part of 
a comprehensive, coordinated approach. As you know, drug abuse 
is a complicated problem which will require a multi-faceted 
solution involving collaboration among diverse professions.
    A comprehensive approach should include several components: 
Law enforcement for control, public/professional education 
prevention, and treatment services.
    These components can be strengthened by policy changes and 
must be implemented in a systematic, coordinated manner 
throughout the State of Maine.
    First, resources must be available to ensure effective law 
enforcement. Drug enforcement agents enforce State and Federal 
drug laws and conduct comprehensive investigations into illegal 
use of methadone, methadone diversion, and other related 
crimes.
    The Maine Drug Enforcement Agency, MDEA, should have 
increased resources--both human and financial--to carry out its 
mission.
    Second, education is essential to the primary and the 
secondary prevention initiatives. Just as we have campaigns to 
educate people about the dangers of smoking, we need programs 
to teach people about the risks they are taking when they abuse 
methadone.
    Healthcare professionals must also receive education on 
this public health crisis so that they may become part of the 
solution.
    Third, comprehensive substance abuse treatment services, 
which offer wide-ranging programs based on best practices, must 
be highly accessible to those who need them. These services 
include medical treatment, cognitive behavioral therapy, and 
other types of rehabilitation and recovery services.
    Treatment services should be integrated into comprehensive 
healthcare delivery systems and need to be responsive to the 
community.
    Currently there are deficiencies in each of the 
aforementioned areas. While the drug abuse problem is 
continuing to grow in Maine, the number of drug enforcement 
officials is shrinking as part of the trend over the past 
decade.
    Budgetary restrictions have forced the MDEA from 76 agents 
in 1992 with an approximate $2 million budget to just 34 today 
with a $1 million budget, and the drug problem has increased 
ten-fold.
    We cannot expect to see positive changes in the drug abuse 
problem in Maine if MDEA resources continue to dissipate. 
Moreover, there is no statewide coordinated approach to 
education.
    State officials need to work with multiple communities--
medical, public health, education, law enforcement--to get the 
word out. Also, treatment services need to be integrated and 
the treatment community must collaborate with other 
stakeholders to ensure a sustainable solution and a reversal in 
the current trend.
    Chairman Collins, Senator Sununu, I implore you to use the 
information you have learned about this issue to craft 
legislation that will help solve the problem.
    I want to close by saying that I have been in law 
enforcement for 31 years. I spent the first 20 years in my 
career in a major urban city. I can tell you that in 1965 in 
the city of Philadelphia, methadone was introduced as the 
panacea to help cure opiate addiction. It did not work in 1966 
and here we are in Maine in 2003, and I do not know that it is 
going to work here. Thank you.
    Chairman Collins. Thank you, Chief. Lieutenant Riggs.

TESTIMONY OF LT. MICHAEL RIGGS,\1\ WASHINGTON COUNTY SHERIFF'S 
                           DEPARTMENT

    Lt. Riggs. Good morning, Senator. Washington County was one 
of the first places in the country where OxyContin abuse 
exploded. A few years ago you started seeing national news 
stories about the ``hillbilly heroin'' taking over rural areas. 
The impression was that one brand-name drug moved into these 
small towns and did all this damage. I would like to begin by 
telling you what actually happened.
---------------------------------------------------------------------------
    \1\ The prepared statement of Lt. Riggs appears in the Appendix on 
page 66.
---------------------------------------------------------------------------
    About 10 years ago we started finding stray pills on 
traffic stops and pat-down searches of somebody's pockets. When 
we would ask them, ``What is this?'' they indicated Percocet or 
Darvocet or some small narcotic pill mixed with Tylenol or 
Ibuprofen or some prescription drug.
    We would ask, ``what is this?'' Well, the story was, I had 
a migraine today and my mother gave me two, and I only took 
one; or I had a toothache and my brother gave me one that his 
dentist gave him when he had a toothache. So they were let go, 
no big deal.
    And then our informants began finding it increasingly 
difficult to buy marijuana or cocaine or LSD. They would come 
out of the house and say, all the guy had was some pills. 
Sometimes they would not even buy them, they did not know what 
they were. They had not heard of them before.
    So those Percocets, Darvocets, Vicodins, and things, those 
are now called little ones. Those are just the little pills. We 
had to educate ourselves as to what it was and what it was 
doing to the people that were addicted to it and how deeply 
rooted this addiction had become.
    In 1996 it started to be OxyContin and that just took over. 
But I do not believe that was their fault. The addiction was 
already deeply rooted within the community.
    It came to a point where my partner and I could not 
remember the last time we purchased marijuana, and we thought 
that was good until we were thinking about it and we realized 
that was bad because what actually happened was the need for 
marijuana or the preference for marijuana had dwindled, not 
gone away, because marijuana and an opiate addict usually do 
not mix. It is like giving a person with a broken leg an 
aspirin. It is not going to do them any good, so they do not 
use it.
    This realization changed the way that we investigated drug 
problems. Opiate addicts were a whole new world. We had to 
educate ourselves about the pills and the addicts.
    The more we lived with the addicts, the more we became 
aware of how powerful the addiction to opiates really is, and 
we have had to understand as much as we could without using the 
drugs ourselves.
    We had to learn new terminology, why they mix cocaine and 
the opiate together and it is called a ``bell ringer.'' We had 
to learn why the Canadians called it ``Shake-n-Bake'' and why 
they preferred it to the American variety, the reason being it 
was very water soluble. All you have to do is put the pill in 
the syringe, suck some water into it, shake it, and you are 
good to go.
    We had to make believers out of doctors, lawyers, 
prosecutors, social workers, employers, parents, and everyone 
in every walk of life. For a long time higher-ups in law 
enforcement would look at all the pills we were getting and ask 
why we could not buy any real dope. People finally started 
realizing this is real dope. This is the worst thing we have 
ever encountered.
    Informants were coming to us saying things like what they 
were seeing was making them sick and angry. One told us of a 
house he just left, an infant was in a car seat on the living 
room floor, and on the couch were two woman covered with a 
blanket and the two guys that lived there had gone after more 
pills.
    The house was cold, there was not any fuel for the furnace. 
The baby's runny nose had dried on its face, they could not 
wash it because the water was frozen.
    Other addicts would tell us, I hate the stuff, I wish I 
never heard of it, and I hope you get it all, but they cannot 
help you because they might need a pill tomorrow.
    Another told us that the only time he had ever thought of 
committing suicide was the last time he was going through 
withdrawal. He said if he had had a gun, he would have shot 
himself.
    We knew of instances where kids would hold other kids down 
at parties and shoot them up because it was funny.
    One of our informants is dead now. His wife was driving too 
fast to get a pill. She is in prison now on unrelated charges 
and her kids are being raised by the grandparents and his house 
is being rented to college students.
    These are just a few examples of the damage this has done.
    For the economics of the whole thing, initially OxyContin 
sold on the streets for $1 a milligram. An addict could use 80 
milligrams a day just to keep from getting sick, never mind 
getting high.
    How do you get $80 a day to support your habit? You lie to 
everyone you know, you steal everything you can, you max out 
all your credit cards, you do not pay any of your bills, you 
cancel your insurance on your car right after you register it 
because you need the refund.
    You get the clerk at the store to knowingly accept a bad 
check if you promise to give them some of the money. You sell 
your body, you sell your children's clean urine to addicts 
being tested.
    After you have got some money, you fake an illness or 
injury and doctor shop until you get a prescription, and then 
you can tell your friends that you go to this doctor and tell 
him that you have these symptoms, he will give them a script. 
Maybe the friends will give you a pill or two in return.
    Or you can buy a few pills from the pharmacy tech who is 
smuggling pills out by tucking them in his socks. You might pay 
the doctor's secretary to steal a script pad for you.
    You can read the obituaries and break into the family's 
home while they are at the funeral.
    This is true; I am not making this up. You can wait for 
your neighborhood cancer patient to go to the doctor. You can 
break in and take his medication.
    Opiate addicts often have bad teeth. This is a blessing in 
disguise because if none of the above work, the emergency room 
doctor will give you a script until you get them fixed, which 
you have no intention of doing because you can do it again at 
another emergency room.
    In closing--I see my time is up--the border does pose an 
issue. One of the big issues is crossing the Canadian border 
and the Canadian exchange in money, the exchange rate.
    The number of pills coming across would be anybody's guess, 
but one dealer told me that he had made a Canadian dealer 
$135,000 in 2 months.
    Another dealer said he could take $5,000 to Canada today 
and in 2 days he would be out of pills and have $6,000. So all 
that money's going across the border and nothing's coming back. 
That is a big impact on the community.
    Chairman Collins. Thank you very much, Lieutenant. 
Detective Pease.

   TESTIMONY OF JASON PEASE,\1\ DETECTIVE SERGEANT, CRIMINAL 
  INVESTIGATIONS DIVISION, LINCOLN COUNTY SHERIFF'S DEPARTMENT

    Det. Sgt. Pease. Chairman Collins, Senator Sununu, I would 
like to thank you for the opportunity to speak for a few 
moments on the impact of the drug problem in the mid-coast 
area.
---------------------------------------------------------------------------
    \1\ The prepared statement of Det. Sgt. Pease appears in the 
Appendix on page 70.
---------------------------------------------------------------------------
    My main focus is that of Lincoln County, but as you all 
know and have heard today, this is not a one-area problem. This 
is statewide.
    Lincoln County has had an increase of epidemic proportions 
in heroin and opiate-based prescription drugs over the past 5 
years. The drug problems surrounding prescription drugs has far 
surpassed all other drugs.
    Over the past 5 years, we in Lincoln County and throughout 
the State of Maine have seen an increase in crime such as 
burglaries, robberies, thefts, overdoses, and even deaths 
because of the drug problem.
    Just to give you an example, 1999--excuse me, 2000 we had a 
local pharmacy in the town of Wiscasset where three gentlemen 
broke into that place by ripping the roof, physically climbing 
up on the roof of the business, taking a wrench and tearing 
apart the roof, and climbing down in. The only saving grace in 
this was that there was a radio alarm inside the pharmacy, but 
when interviewed and talked to about this, during and after the 
event, the only reason they were there was for prescription 
OxyContin.
    Since that time one of the subjects has been sent to a 
rehab in New Hampshire by his family. He spent half a year 
there, and after that he was released and overdosed in 
Manchester.
    Since being assigned to the Criminal Investigations 
Division of the Lincoln County Sheriff's Office in 1999, I have 
handled numerous investigations into the theft of prescription 
pads from doctors' offices, altering of prescriptions, forging 
of prescriptions, and I have even dealt with subjects that have 
been manufacturing prescriptions on their computers.
    It is a common occurrence in the mid-coast area. When I say 
mid-coast area, I am concentrating on northern Cumberland 
County, Sagadahoc County, Lincoln, and portions of Knox County.
    Subjects are going into doctors' offices and while they are 
waiting for the doctor to come in or the doctor is out getting 
something for them, they are rummaging through the drawers and 
finding left-behind prescription pads that are blank and 
already have the DEA number attached to it, so all they have to 
do is scribble on it and take it to a local pharmacy and get it 
filled.
    As I mentioned, we had a couple of cases where there were 
people taking prescriptions that they obtained and scanning 
them into their computer, changing the date and changing the 
location and being able to print those off to look exactly like 
those prescriptions given by the doctor, and they have been 
able to pass those successfully.
    At first we found the majority of prescription drug users 
and abusers started using the prescriptions because of 
illnesses, pain, or to wean themselves off of heroin. But now 
it has been found that many of the users and abusers are on 
prescriptions because of their ability to obtain the dose 
easier by going to the doctor.
    Where in the past heroin users and sellers were able to go 
to Massachusetts and buy the packet of heroin for $5 and return 
to Maine and sell it for $25 to $35 a packet, that is a pretty 
good profit margin, now they are able to go to their doctor and 
get a prescription for OxyContin, Percocet, Vicodin and spend 
$25 and be able to turn around and make twice as much as they 
were spending on selling and buying the heroin.
    They are getting a price of approximately $1 a milligram on 
OxyContin at this point and it is costing them $40 to get the 
prescription filled and they are turning around and making 
about $250 on one bottle.
    Currently we are seeing OxyContin, hydrocodone, Fetynal 
patches, Xanax, methadone, and Loratab. These prescription 
drugs are all opiate derivatives which seem to be the ``hook'' 
for the person using and abusing.
    OxyContin has by far been the worst prescription abuse in 
the mid-coast area over the past few years of any prescription 
that contains opium or synthetic opium and is the drug of 
choice.
    We have experienced numerous instances where subjects from 
outside of Lincoln County were traveling to doctors in our area 
in order to get multiple prescriptions from those doctors.
    The subjects would travel to doctors in small towns such as 
Waldoboro, Damariscotta, and Wiscasset and visit a family 
medical office. The subjects were from areas like Brunswick, 
Augusta, and even, at some points, Portland. Again, Brunswick 
has two major hospitals, Parkview and Mid-Coast Hospital, and 
hundreds of doctors in that area, so they are choosing to come 
to the rural area because there is less knowledge of who is who 
in the town, and they are just coming in and moving into these 
little towns and are able to get those prescriptions filled.
    This is what is referred to as doctor shopping, and this 
again is not a local Lincoln County problem. This is a problem 
statewide.
    As you talked about, we have had successful cases involving 
doctor shopping where a specific incident, a couple coming from 
Brunswick and going throughout Lincoln County to the towns of 
Boothbay, Boothbay Harbor, Wiscasset, Damariscotta, and 
Waldoboro, these little towns getting at least one, if not two, 
prescriptions from different doctors in those towns. And then 
they were able to pass all those prescriptions successfully and 
even in some of those cases we have had them using the VA to 
accomplish the same goal. They are going to Togus to get their 
prescriptions filled also.
    In similar acts, when making, forging, or filling ``doctor 
shopping'' prescriptions, they are traveling to small local 
pharmacies. The reason for filling prescriptions in small 
pharmacies is they do not have the tracking system such as a 
Hannaford or a Rite-Aid does.
    Another problem we have noticed--Ms. Johnson kind of talked 
about this--is that the younger crowds are going into their 
parents' or their grandparents' or their family's medicine 
cabinet and taking pills. Most of the time the prescriptions 
are pain pills, they are narcotics they are taking, but from 
time to time they are just taking any random pill and doing 
what she said, taking them to parties and emptying them into 
bowls.
    Another problem that we have seen is leftover 
prescriptions, family members giving other family members pain 
killers, as a mother giving her son her leftover Percocet 
because he has got a bad back and he does not have a 
prescription for it, but they are probably addicts.
    As we in law enforcement in Maine know, the United States 
is dealing with the dilemma of prescription drug abuse. If 
there was some method of linking all doctors and all pharmacies 
to one system of tracking prescription drugs to clients, it may 
assist in the fight against drug abuse. I know we talked about 
the drug program and the prescription program.
    There are such systems in place tracking motor vehicles, so 
I feel we can come up with an adequate system for the 
prescription drug problem.
    Again I would like to thank you for your time and I am 
willing to answer any questions that you may have.
    Chairman Collins. Thank you very much, Detective.
    I want to thank each of you for painting such a vivid 
picture to the Committee on the impact of drug abuse in your 
communities and on the people that you are serving.
    I also really appreciate your commitment to law 
enforcement. We are grateful for all that you are doing on the 
front line.
    Chief, let me start with you. First let me thank you very 
much for bringing the vials so that we could actually see what 
we are talking about when clinics are giving doses of methadone 
for their patients to take home.
    There has been dispute on whether or not the treatment 
clinics are a significant source of the methadone that is 
diverted and used.
    What is your judgment? Do you think that the majority of 
the diverted methadone does come from clinics? Or do you think 
that it is from pain prescriptions? What is your feeling on 
that?
    Chief Chitwood. In my opinion, in the City of Portland and 
in the greater Portland area, the majority of the diverted 
drugs are coming from the two clinics and have come from the 
two clinics.
    Here is a perfect example. One clinic, one patient, take-
home methadone, hoarded it to sell it for heroin. In this 
particular case, this individual was given take-home methadone, 
he was a career criminal with a criminal record in three 
States, and they are entrusting him to take vials of 340 
milligrams home, and he gave a fatal dose to his friend.
    That is where I see it. We very seldom see anything coming 
from a prescription. The prescription is usually in the pill 
form, and it is usually 10 milligrams. So we are not seeing 
that as a problem.
    All the diversion, all of the deaths, all the crime scenes 
where we go and investigate the deaths, there has been 
methadone involved in it, it is a vial, and usually the name is 
rubbed off the label of the vial.
    Chairman Collins. And do you see the trend toward megadoses 
of methadone for treatment purposes as contributing to the 
diversion?
    Chief Chitwood. I see it as a problem in this sense, and 
this is based on law enforcement experience.
    When you have somebody taking 400 and 500 milligrams of 
methadone, they are zombies. And I believe that that type of 
megadosage causes problems beyond the diversion problem.
    Inebriation on the highways include problems with being 
able to function as a human being and function normally, and I 
think that from that perspective it is a problem.
    How do you get somebody off of 400 to 500 milligrams of 
methadone? So now you have created craving. Does it do away 
with the cravings? Yes. But now they have the craving for 
methadone.
    These particular clinics are for-profit. How long are they 
going to take $80 to $100 a week from their client, especially 
if their client is a career criminal who has to steal, rob and 
pillage to survive? That is an issue.
    Chairman Collins. Thank you. Lieutenant Riggs, you have 
painted a very vivid picture of the impact of drug abuse on a 
rural county in increase in crime and destroying families.
    Could you elaborate on the issue of being on the Canadian 
border as Washington County is. Does that increase the chances 
for diversion of drugs? Are there Canadian sources that are 
contributing to the drug abuse problem in Washington County and 
the OxyContin problem in particular?
    Lt. Riggs. Yes, ma'am. Oxycodone is smuggled into this 
country on a daily basis with a great deal of frequency.
    By walking the St. Croix river, they come across in body 
cavities, they come across in vehicles, they come across on jet 
skis. They come across about any way that you can imagine but 
rarely by air.
    The really ingenious efforts of the drug traffickers--one 
particular gentleman has an American fishing boat. He takes a 
little remote control boat into the Canadian shore, and the big 
boat does not touch the Canadian shore, and they run a little 
remote control boat into the Canadian land and it is picked up 
by his connection and brought back to the fishing boat, and he 
has never touched the Canadian shore.
    So diversion in Canada occurs by very organized groups of 
doctor shoppers that include everything from children to old 
people.
    That is brought all together to individual dealers and 
distributed from there across the borders into the State in 
fairly substantial quantities as a whole.
    One of the things that we rarely see is somebody coming 
across the border with a thousand pills. You see them coming 
across the border with 20 pills, 50 pills, but there are a 
dozen of those people a day coming across or more.
    So you are having an influx of hundreds of pills per day, 
at least, coming across the border.
    Chairman Collins. Is there any cooperative effort between 
Maine officials and Canadian officials underway to try to 
better detect and deter the transportation of these drugs?
    Lt. Riggs. Yes, there is, and our Canadian counterparts are 
just as cooperative as they can be.
    We find the officers on the streets, whether it is people 
like myself or an MDEA officer or the drug unit or intelligence 
unit, we all cooperate with one another, we all share 
information the best that we can until guidelines and rules and 
regulations prohibit sharing of that information.
    When it gets into more in-depth investigations, a lot of 
material has to be cleared through Ottawa before we can even 
become privileged to it. That is a long process.
    Chairman Collins. I appreciate your identifying that area 
for us.
    Detective Pease, you talked about doctor shopping 
particularly in smaller communities where the local pharmacy is 
not going to have a sophisticated tracking system for 
prescriptions that might catch duplicative prescriptions for 
the same drug.
    Could you comment on the elements of an effective 
prescription tracking program--the State of Maine has recently 
passed a law as have some of the other States--do we need some 
sort of nationwide system in order to deal with doctor 
shopping?
    Det. Sgt. Pease. Well, what little I know about nationwide, 
but I feel this is obviously a problem that is nationwide and 
we need to have something real-time.
    We need to have something so that when a doctor or a PA or 
somebody writes out a prescription for a person, they are able 
to pull that name up using an office computer into a central 
system that they can look and see if this person has gotten 
three prescriptions for oxy or methadone or whatever the 
medication may be, and then that would raise some suspicions.
    I think that would be beneficial to us. I realize that we 
have some issues of the client/doctor privilege, and we as law 
enforcement run into that quite frequently.
    The only time we can get around that is if we can show that 
it is a fraudulent prescription. In Maine State law there is a 
provision for law enforcement to obtain that information, but 
that is still very hard to do even when you present the 
physicians with that law. It is a hard sell because they do not 
want to believe that it is a fraudulent prescription.
    Back to the smaller pharmacies, in our area most of the 
pharmacies that are that small are owned or run by the 
different companies, but they are much smaller than a Hannaford 
or a Rite-Aid, so they do not have that ability to set up 
something.
    They are all for it and they try to keep tracking this 
information for us as much as they can without violating those 
patients' rights.
    But when they start seeing people coming from Brunswick or 
Portland or Augusta all the way down to Waldoboro, Maine, they 
start to raise their eyebrows that something is going on here.
    Chairman Collins. Thank you. Senator Sununu.
    Senator Sununu. Chief Chitwood, you expressed concern that 
in an urban area like Philadelphia you have seen problems with 
certain approaches to treatment or diversion of methadone and 
you talked about seeing some of those problems here.
    Can you come up with a more positive experience from your 
work in Philadelphia? Was there anything that you have seen 
here in Portland that you think is unique or uniquely effective 
in a rural area that might not work in an urban setting but 
something that we will need to focus on to try to address this 
problem in a rural setting?
    Chief Chitwood. I think that when you look at the opiate 
issue--for 10 years I have been telling people in Maine this is 
a problem that is going to be a crisis and here we are--if you 
are going to look at treatment, I believe there is a place in 
treatment for methadone, but it has to be a comprehensive 
program.
    To say that--and I call it a drive-by window--to say that, 
OK, you have a heroin problem or you have an opiate problem, we 
are going to give you 400 or 500 milligrams of methadone, and 
you are going to live life and everything is going to be fine, 
I think is having your head in the sand.
    I believe they need counseling. I believe that you need 
some type of daily collaborative approach between the patient 
and social workers, psychologists, and maybe methadone can be 
part of that treatment.
    I think that what we have seen--or what I have seen in the 
methadone history--years ago you had a window. You went up, you 
took it, and you walked out. But you went right back on the 
street.
    Now the thing is these megadoses. That is the ``new 
technology, or new medical practice.'' I believe it may work in 
some cases.
    But when you see the numbers of deaths, it is not working. 
But I believe we need a comprehensive program, and methadone 
may be a part of that initial program, but I do not believe 
that we are approaching it correctly.
    Senator Sununu. You indicated that a common prescription 
dose would be 10 milligrams?
    Chief Chitwood. I believe it is 10 milligrams.
    Senator Sununu. Just for comparison, how many milligrams 
are represented in the vials?
    Chief Chitwood. This is 340 milligrams. Some of these vials 
are 60, and 45.
    Again, the young lady I spoke about, she was on a high 
dosage, 210 milligrams, so you can see the difference. 
According to the medical people that I have talked to, the dose 
should be around 80, 80 to 100 milligrams.
    Senator Sununu. Lt. Riggs, are there any specific changes 
or recommendations that you would want to make for the 
modification at the local or the State level or the Federal 
level to help you do your job better?
    Lt. Riggs. Yes. One thing I wanted to touch on regarding 
the conversation about methadone is confidentiality. 
Confidentiality has got to be maintained, but changed. We 
cannot talk to doctors and be able to have doctors answer our 
questions. They cannot speak with us. It is very unproductive.
    I talked to my own doctor about other patients, he cannot 
discuss it with me. I'll tell him, this one and this one and 
this one is selling it. I know that they are going to their 
doctor, I know what they are getting for medication, I know 
what they are on, and I know they are selling it on the side.
    On a much larger scale, law enforcement is being segregated 
from sharing vital information more and more all the time.
    A year ago I could pull pharmacy records; today I cannot 
because of the HIPAA laws. There is no way around that. They 
are segregating law enforcement more and more. Instead of 
easing the confidentiality and fostering communication, we are 
being shut out of the picture.
    Reviewing the narcotic tracking program in the State, the 
information to law enforcement is not part of that. I need it 
to more effectively do my job. It has become increasingly 
difficult to communicate and share information because of 
confidentiality.
    Senator Sununu. Thank you all very much.
    Chairman Collins. Thank you, Senator.
    Just one very quick question before I let you go.
    We talked about various recommendations this morning and we 
touched on systems such as tracking, treatment centers, better 
education, and the confidentiality. We talked about a more 
multi-faceted approach.
    The one issue that has not come up that I want to ask you 
is whether we need tougher penalties. Lt. Riggs.
    Lt. Riggs. Ma'am, if we were to actively enforce the laws 
that are already on the books, we would not have to be here 
today. That is my opinion.
    Chairman Collins. Thank you. Chief.
    Chief Chitwood. It is a matter of having people to enforce 
it. It has to be a multi-faceted approach. No one approach is 
going to solve this problem. It has to be enforcement, 
education, and rehabilitation. It is not going to work unless 
you have those three.
    Chairman Collins. Thank you. Detective.
    Detective Pease. Senator, I would like to agree with both 
of them. The guidelines and the law, the prosecution to enforce 
and our ability of having to fulfill the need for prosecution 
by building a strong and good case, and, most importantly, with 
the DA's office and the AD's office, we are able to build those 
stronger penalties or fulfill what we already have and it will 
work.
    Chairman Collins. Thank you very much. That is very helpful 
to get your honest view on that issue.
    I want to thank all three of you. All of you have come from 
long distances to be here today. It was extremely helpful, and 
thank you for your testimony.
    We are now going to hear from our final panel today.
    Dr. Richard Dimond is a retired Army physician with an 
extensive background in teaching and research. He retired in 
Southwest Harbor in 1994, and at the time was a very active 
member of the community.
    One of his most recent projects is as the organizer of a 
group of citizens who are very concerned about the drug problem 
in their midst.
    Barbara Royal is the administrative director of the Open 
Door Recovery Center in Ellsworth. This is an out-patient 
substance abuse treatment center. It is the only such facility 
in Hancock County, and as such it deals daily with the dramatic 
and increasing shift toward prescription drug abuse.
    We welcome both of you.
    Dr. Dimond, I am going ask that you go first.

 TESTIMONY OF RICHARD C. DIMOND,\1\ M.D., MOUNT DESERT ISLAND 
                        DRUG TASK FORCE

    Dr. Dimond. Chairman Collins, Senator Sununu, thank you for 
the opportunity to testify on the increasing use of 
prescription drugs in Hancock County.
---------------------------------------------------------------------------
    \1\ The prepared statement of Dr. Dimond with an attachment appears 
in the Appendix on page 72.
---------------------------------------------------------------------------
    Alcohol and drug abuse, including opiate drugs and drug-
related crimes, are not new to Southwest Harbor, Mt. Desert 
Island--hereafter referred to as MDI--or Hancock County, but 
these problems have escalated exponentially over the last 4 or 
5 years.
    By 1999 and 2000, many of us were becoming educated by the 
U.S. Attorney in Bangor about the sudden increase in overdose 
deaths in Penobscot and Washington Counties. We learned about 
prescription narcotics being used to supplement or substitute 
for heroin and how they have given rise to an industry 
characterized by drug-related burglaries, stealing and dealing, 
and doctor shopping to obtain prescriptions which were 
marketable by themselves.
    Particularly alarming were reports of overdose deaths 
occurring in individuals in their mid-20's and addiction to 
both heroin and prescription narcotics being recognized in 
teenagers.
    About that time, several Southwest Harbor businesses, 
including our pharmacy and one of our two medical clinics, 
experienced breaks-ins and attempted or successful burglaries 
that fit the picture of drug-related crimes.
    Similar occurrences in Bar Harbor and an increasing concern 
about our adolescent population led to the formation of an MDI 
Task Force Education Committee in the fall of 2000 followed by 
two public forums about heroin and narcotic abuse in our area.
    Unfortunately, by the fall of 2001, it was clear that 
initial enthusiasm for the formation of a Task Force Against 
Drug Abuse on MDI had been short lived.
    Over the next year and a half, numerous arrests for 
possession of illicit drugs and/or drug trafficking were made, 
and the local press provided many reports of escalating drug 
abuse statewide and in our area.
    Most alarming, however, was the increased frequency with 
which members of the community found drug paraphernalia, such 
as syringes and needles, behind buildings, near dumpsters, in 
the street, and on their private property.
    Despite reporting such occurrences and other suspicious 
activities to our local police, citizens became increasingly 
frustrated because they saw little change and the situation 
seemed to be getting worse. Thus, explanations that a five-man 
police force is not equipped to do surveillance or drug-related 
investigative work, and that the State only had three drug 
enforcement agents covering the four counties in our area were 
of little comfort.
    Finally, a Southwest Harbor boat builder and fisherman 
stood up at the Board of Selectmen's meeting on May 7 of this 
year holding a zip-lock plastic bag containing several syringes 
and needles found recently on his property and demanded that 
something be done.
    On May 29--3 weeks later--225 residents of MDI and 
neighboring communities gathered in Southwest Harbor with a 
panel of eight experts representing different professional 
disciplines to discuss drug abuse and drug trafficking.
    Emphasizing that there is no simple solution to these 
difficult problems, all panel members underscored the reality 
that only a multi-disciplinary approach, including effective 
education, treatment, law enforcement, and prevention 
strategies, is likely to make a significant difference. 
Nevertheless, residents were most outspoken about the immediate 
need for increased support from law enforcement.
    Consequently the audience became increasingly frustrated 
with State law enforcement officials who repeatedly explained 
that there were insufficient funds and manpower to assign a 
Maine Drug Enforcement Agency agent to Hancock County in the 
foreseeable future.
    Subsequently, discussions were held between local police 
departments, the sheriff, the district attorney, the director 
of MDEA, and the county commissioner. As a result, the sheriff 
proposed formation of a county-wide drug enforcement team, the 
only one of its kind in the State, to be made up of three 
officers from local police departments who would be trained by 
MDEA and assigned permanently as MDEA agents in Hancock County 
with authority to enforce anti-drug laws statewide.
    The proposal was discussed at a public hearing in Ellsworth 
on July 22 and creates a real partnership between Hancock 
County and MDEA, between the county citizens and the State.
    The cost of this program is about $200,000 to hire three 
new police officers to replace the individuals assigned to the 
County Drug Enforcement Team. Although this means a further 
increase in county taxes, the proposal appeared to be supported 
by most of the individuals attending the hearing, as well as by 
more than 200 residents of MDI and the Cranberry Isles.
    This proposal to strengthen investigative law enforcement 
in our area is the first step in what we hope will be a 
powerful community response that effectively interrupts the 
flow of drugs through Southwest Harbor, Mount Desert Island, 
and neighboring communities in Hancock, Penobscot, and 
Washington Counties.
    However, multiple other initiatives are needed as well, 
particularly in the areas of education, treatment, and 
prevention.
    As is true of many rural States, Maine's resources for 
treatment of alcohol and opiate addiction are woefully 
inadequate. Currently, Hancock County has only one intensive 
out-patient treatment program, no emergency in-patient 
resources for opiate detoxification, and no residential in-
patient treatment facility.
    Maine initiated its Adult Drug Treatment Court Program in 
2001 in six jurisdictions, but not in Hancock County. 
Nevertheless, we are hopeful that an Adult Drug Treatment Court 
will be established here in the near future.
    Finally, although long-term residential therapeutic 
communities similar in scope to the Day Top Program in 
Rhineback, New York, have also proven to be efficacious in the 
treatment of alcohol and opiate addiction, no such program 
exists in Maine or northern New England. It should be noted, 
however, that the Maine Lighthouse Corporation in Bar Harbor is 
actively seeking to establish such a treatment facility.
    Perhaps even more important in the long run will be the 
development of effective strategies focused on prevention. One 
such program is The Edge, which is a combined educational and 
recreational program for children in Washington County during 
and after school hours that is operated by the Maine Sea Coast 
Mission in Bar Harbor.
    Other efforts are being initiated on MDI through a 
coalition, sharing an Office of Substance Abuse Prevention 
Grant.
    As you know, Maine has experienced a shocking increase in 
opiate overdose deaths in the last 5 years, and most of these 
deaths were caused by prescription narcotics, especially in 
combination with anti-depressants and alcohol.
    Ten of the 256 overdose deaths occurring in the last 2 
years involved residents of Hancock County, and one of the 
latter lived in Southwest Harbor. Tragically, a young Bar 
Harbor man died of a prescription overdose in May, as did a 
young Bangor man in June after being arrested and lapsing into 
a coma in Ellsworth.
    Between July 10 and July 17, five burglaries occurred in 
Southwest Harbor fitting the picture of drug-related crimes, 
and a Swans Island couple was robbed, bound, and threatened by 
an individual who took $40 and a container of prescription 
drugs.
    Last, a Southwest Harbor couple was arrested on July 18 for 
heroin possession.
    Previously it was thought that such problems were 
encountered only in urban areas of the country. Clearly, they 
have engulfed the rural State of Maine as well, including 
Hancock County and Mount Desert Island.
    Accordingly, the following recommendations seem 
appropriate: Federal funding of programs that support 
education, treatment, law enforcement, and prevention efforts 
to combat alcohol abuse, illicit opiate abuse, and prescription 
drug abuse must be increased;
    Federal funding should also be provided to support a pilot 
study of Maine's recently enacted Prescription Drug Monitoring 
Bill--LD 945;
    Federal legislation creating a national prescription drug 
monitoring system should be considered; and
    Similarly, Federal legislation promoting the sharing of an 
international prescription drug monitoring system between the 
United States and Canada should be considered as well.
    In closing I would like to read a short passage from a 
letter in a local newspaper written by the parents of a young 
Hancock man who died of an overdose in May.
    ``We have seen that there are dangers that we as a society 
are ready to protect our children and ourselves against. They 
include inexperienced drivers, impure water and air, and 
improper electrical wiring to name only a few.
    ``We urge you in your capacity as Hancock County 
commissioners to protect our children and the future of Hancock 
County from the pervasive, merciless problem of drug abuse by 
curtailing the easy availability of illicit drugs through 
increased law enforcement as well as greater support for more 
intensive drug rehabilitation programs.''
    I would like to thank the Kings publicly for giving me 
permission to share their plea with you as well. Thank you.
    Chairman Collins. Thank you very much, Doctor. Ms. Royal.

 TESTIMONY OF BARBARA ROYAL,\1\ ADMINISTRATIVE DIRECTOR, OPEN 
                      DOOR RECOVERY CENTER

    Ms. Royal. Thank you, Chairman Collins and Senator Sununu, 
for having me here today.
---------------------------------------------------------------------------
    \1\ The prepared statement of Ms. Royal appears in the Appendix on 
page 77.
---------------------------------------------------------------------------
    I come here as a provider. I provide treatment assistance 
at Open Door.
    We, too, like everyone else who has spoken here today, 
experience the results of what--I really agree 100 percent with 
Detective Riggs from Washington County.
    I see this as a problem that started many years ago and has 
evolved to what we see here today. I do not isolate one drug or 
one substance out as the problem. I see this as an addiction 
problem.
    We have a new tool that we use with adolescents in 
treatment at Open Door and we have a difficult time 
understanding how dangerous it is to be in the same place as 
the drug. We put a bag of pot in the middle of the room, it 
cannot hurt you. If it sits in the middle of the room, nothing 
bad is going to happen. The minute you pick it up, you are in 
danger.
    That is what is happening. If we take that analogy and use 
it as a State, we put OxyContin in the middle of the State--or 
any other substance, heroin, pot, alcohol, any other 
prescription drug--it is no danger to us if used appropriately, 
if it is used the way it is intended to be used. The minute it 
is picked up, used and abused, sold, it becomes a problem and 
that is what happens.
    Now we are seeing a situation where we are dealing with a 
wave of addiction--I describe it as a tidal wave--we are all 
standing on the shore. We get hit by a few of the smaller 
waves, it is still coming, we have not seen full impact. And 
that is where I stand today. I stand there watching this huge 
thing coming our way.
    Over the past 6 to 8 weeks, just at Open Door alone, we 
have seen about a 50 percent increase in walk-ins in just the 
past 6 to 8 weeks. I am talking primarily heroin addicts, but 
we are also looking at poly substance abusers pretty much 
across the board, all substances that can and are abused.
    Most of the time we cannot find places to put them. There 
is no treatment available--when there is treatment available, 
it is nowhere near enough. So most of the time by the time our 
day ends at Open Door, we have many people who we have not been 
able to help. We have not been able to find places where they 
truly need to be.
    There is a serious problem with the lack of detox. It 
definitely comes back to funding. It also comes back to 
education for medical staff and education for the general 
public.
    My feeling today, I have this tremendous opportunity to sit 
here in front of you and say to you, one of my primary reasons 
for sitting in this chair today is because people are suffering 
unmercifully. Families are suffering. Families are losing their 
babies.
    Anyone who has lost someone--15, 16, 17, 21, 22--when you 
lose a child, life is never the same. It is happening more and 
more and more and more.
    I have a tremendous passion for the work that I do. My 
staff has a tremendous passion for the work that they do, 
because on a daily basis we work with people who are truly 
desperate and suffering.
    We need the multi-faceted approach that several people have 
mentioned here today. We need prevention, education, we need 
detox treatment, and we need law enforcement. We need a 
balanced scale, we need to approach this from all directions 
equally.
    I refer to that as the three-legged stool. You saw off one 
leg, the stool falls over. If you have three solid legs, that 
stool will stand forever, and that is what we need.
    In Ellsworth alone we have a project that we have been 
working on for several weeks now along with many other areas 
around Portland, Bangor. It is called Ultralight, which is a 
story of the writer's brother's own overdose to heroin.
    We are in the process of bringing the play to Ellsworth in 
September, and the reason I mention that is that what we have 
watched over the past few weeks since the general public became 
aware of the project, we have had every walk of life offer to 
help. They say, I will do anything.
    Everyone from our local sheriff to our president of the 
bank, to people who run our local organizations and businesses 
have stepped forward and said we want to come together as a 
community. That is just one example.
    There is a lot of work to be done. I appreciate your 
willingness to be here to today. Thank you.
    Chairman Collins. I want to thank both of you for your 
eloquent testimony.
    Ms. Royal, are you seeing a trend towards younger people 
coming to your clinic?
    Ms. Royal. We definitely are. Open Door has an age-range 
outpatient program for adolescents. Up until a year ago, age 14 
to 18. We had to lower that age to 13 this past year.
    We have referrals for 12-year-olds that we will not treat, 
and we refer them to other independent providers. We are just 
not equipped to deal with that young age group at this time, 
but definitely younger and younger.
    The other problem that we have seen along with that is that 
these young people range from approximately, well, 15 all the 
way up to 25.
    They are kind of skipping over prescription drugs and 
heading right into the heroin use because it is easier access 
and cheaper to buy.
    Chairman Collins. It is so troubling to think of some 13- 
and 14-year-olds already in trouble with drug abuse.
    Are you also seeing an increasing number of clients who are 
abusing legal drugs, prescription drugs, as opposed to heroin 
and other illegal drugs?
    Ms. Royal. We are. The population that we find are most 
affected at this point by legal drugs, prescription drugs, and 
are between the ages of 18 and 25. We do all of the drug 
testing for the Department of Human Services in our area. So 
very often on a daily basis we have young people walking in who 
have just had their children taken away from them. We do the 
drug testing. We try to get them prepared for treatment.
    That age group, that age range, tends to be the hardest hit 
for the prescription drug abuse.
    Chairman Collins. Dr. Dimond, I want to congratulate you 
for your leadership in organizing and spearheading the 
partnership that is leading to increased emphasis on law 
enforcement assets to deal with this problem.
    As a physician, do you also find that there has been a 
severe shortage of treatment options in Hancock County? I think 
Ms. Royal's facility is the only facility in Hancock County.
    Is that part of the problem as well?
    Dr. Dimond. Sure. In fact, Open Door is the only intensive 
out-patient program in Hancock County. There are no acute 
detoxification resources on an in-patient basis anywhere in the 
area, and there is no residential treatment facility in Hancock 
County.
    But beyond that, as you know and Senator Sununu from New 
Hampshire, in rural States, the number of professionals in the 
area of mental health and addiction is preciously few so that 
people have little to no real access to care. It is a different 
dimension of the problem, forgetting whether or not they have 
the training to help people.
    Chairman Collins. That was going to be my next question to 
you because I think that not only do we lack the facilities, 
but we lack the health care providers who have expertise in 
treating addiction; and I have also seen that in the work that 
I am doing on the problem of mentally ill children not getting 
the treatment that they need. Senator Sununu.
    Senator Sununu. Thank you very much.
    Dr. Dimond, you talked about the need for additional 
funding or additional resources, and your effort has obviously 
been very successful.
    Did you run into any resistance at the local level? Any 
resistance to the efforts or to the concerns that you were 
raising?
    Dr. Dimond. Surely. As you well know, that involves taxes 
and there was a proposal on the table that called for an 
increase in county taxes, and understandably people are very 
concerned about that. That is not a popular thing in the face 
of a country that has decreasing Federal funding to a State 
that has decreased funding. MDEA has been flat funded in the 
State of Maine for years and now we have statistics, at least, 
of what is going on.
    So as the need goes up, if you are lucky the funding stays 
the same. I do not think so.
    So the solution is coming out of the taxpayers' pockets and 
is hard to accomplish; but I have to say in all honesty to 
think that I am sitting here in front of you and asking you for 
Federal dollars that are not going to come out of the 
taxpayers' pockets would be a dream world. But it is a world 
that needs to happen as a priority one way or the other.
    Senator Sununu. Ms. Royal, of the heroin addicts that you 
treat at your center in Ellsworth, how many of them, what 
portion of them, began by using prescription drugs?
    Ms. Royal. Several. Many--and some of them as mentioned 
today start out as patients who have been in a car accident or 
some kind of injury and started out getting a legitimate 
prescription that they truly needed for pain management and, 
unfortunately, oftentimes their dependence has often led to 
addiction and other serious problems.
    Percentage-wise, I would say that--I am certainly not going 
to say 100 percent, but I am going to say somewhere between 75 
and 80 percent.
    Senator Sununu. Your center is a for-profit center or not-
for-profit?
    Ms. Royal. Nonprofit.
    Senator Sununu. With regard to the for-profit treatment 
facilities that Chief Chitwood spoke about, what is their 
revenue model? What source do they derive their revenues, and 
do you have any strong feelings about the approach to revenues 
or the approach between profit and nonprofit centers?
    Ms. Royal. I am sorry, I am really not sure. I would make a 
guess and I would say that for some that may be insurance, 
Medicaid, but I am not sure. Being nonprofit, we do get some 
State funding through the Office of Substance Abuse and 
Medicaid, and the rest of that is through private donations and 
grant writing.
    Senator Sununu. And has the State or any of the providers 
tracked different levels of performance between facilities?
    Ms. Royal. Our facility is not a medical facility. We do 
not prescribe any medications. We are purely substance abuse 
treatment, so in that sense they differ.
    Senator Sununu. I see.
    Ms. Royal. I do not know enough about the for-profits to 
know exactly how the funding is obtained.
    Senator Sununu. Thank you very much. Thank you again to 
both of you.
    Chairman Collins. I want to thank you very much for being 
with us today and for your comprehensive testimony. It is 
extremely helpful to us as we seek to address this critical 
problem.
    We have been able to hear today from a variety of 
perspectives and experts across the board in many fields. That 
will help us as we return to Washington to craft measures to 
address this burgeoning problem.
    I want to thank everyone for their time and their 
commitment. I also want to thank my staff which has worked very 
hard to put together this hearing.
    And I particularly want to thank Senator Sununu from New 
Hampshire for being here today. I very much appreciate it, 
particularly since I promised him a lobster lunch but he has to 
run and get his plane so I am not going to be able to keep that 
commitment.
    Senator Sununu. I am sure you will make good on it.
    Chairman Collins. We will do our best. I know Senator 
Sununu's commitment to this issue prompted his participation 
today, and I am very grateful for his being here.
    The hearing record will remain open for 15 days.
    I know that some families who have experienced the horrible 
tragedy of losing a loved one to a drug overdose wish to submit 
testimony or a letter for the record. We very much welcome 
that, and our staff will work with you.
    I just want to thank a lot of the family members who have 
taken the time to be here today. You are the reason that we are 
pursuing this issue, and I want to thank you very much for your 
participation as well.
    This hearing is now adjourned.
    [Whereupon, at 12:28 p.m., the Committee was adjourned.]


                            A P P E N D I X

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