[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
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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
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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
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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.
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\1\ The chart referred to appears in the Appendix on page 82.
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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.
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\2\ The chart referred to appears in the Appendix on page 83.
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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.
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\1\ The prepared statement of Dr. Greenwald appears in the Appendix
on page 84.
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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\
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\1\ The study submitted for the Record appears in the Appendix on
page 114.
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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.
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\2\ The prepared statement of Dr. Sorg appears in the Appendix on
page 45.
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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.
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\1\ The prepared statement of Dr. Burton with attachments appears
in the Appendix on page 48.
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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.
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\1\ The prepared statement of Chief Chitwood appears in the
Appendix on page 60.
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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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