[House Hearing, 110 Congress]
[From the U.S. Government Publishing Office]


 
                    NASPER: WHY HAS THE NATIONAL ALL
                   SCHEDULES PRESCRIPTION ELECTRONIC
                  REPORTING ACT NOT BEEN IMPLEMENTED?

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

                                HEARING

                               BEFORE THE

              SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

                                 OF THE

                    COMMITTEE ON ENERGY AND COMMERCE
                        HOUSE OF REPRESENTATIVES

                       ONE HUNDRED TENTH CONGRESS

                             FIRST SESSION

                               __________

                            OCTOBER 24, 2007

                               __________

                           Serial No. 110-73


      Printed for the use of the Committee on Energy and Commerce

                        energycommerce.house.gov

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                    COMMITTEE ON ENERGY AND COMMERCE

                  JOHN D. DINGELL, Michigan, Chairman

HENRY A. WAXMAN, California          JOE BARTON, Texas
EDWARD J. MARKEY, Massachusetts          Ranking Member
RICK BOUCHER, Virginia               RALPH M. HALL, Texas
EDOLPHUS TOWNS, New York             J. DENNIS HASTERT, Illinois
FRANK PALLONE, Jr., New Jersey       FRED UPTON, Michigan
BART GORDON, Tennessee               CLIFF STEARNS, Florida
BOBBY L. RUSH, Illinois              NATHAN DEAL, Georgia
ANNA G. ESHOO, California            ED WHITFIELD, Kentucky
BART STUPAK, Michigan                BARBARA CUBIN, Wyoming
ELIOT L. ENGEL, New York             JOHN SHIMKUS, Illinois
ALBERT R. WYNN, Maryland             HEATHER WILSON, New Mexico
GENE GREEN, Texas                    JOHN B. SHADEGG, Arizona
DIANA DeGETTE, Colorado              CHARLES W. ``CHIP'' PICKERING, 
    Vice Chairman                    Mississippi
LOIS CAPPS, California               VITO FOSSELLA, New York
MICHAEL F. DOYLE, Pennsylvania       STEVE BUYER, Indiana
JANE HARMAN, California              GEORGE RADANOVICH, California
TOM ALLEN, Maine                     JOSEPH R. PITTS, Pennsylvania
JAN SCHAKOWSKY, Illinois             MARY BONO, California
HILDA L. SOLIS, California           GREG WALDEN, Oregon
CHARLES A. GONZALEZ, Texas           LEE TERRY, Nebraska
JAY INSLEE, Washington               MIKE FERGUSON, New Jersey
TAMMY BALDWIN, Wisconsin             MIKE ROGERS, Michigan
MIKE ROSS, Arkansas                  SUE WILKINS MYRICK, North Carolina
DARLENE HOOLEY, Oregon               JOHN SULLIVAN, Oklahoma
ANTHONY D. WEINER, New York          TIM MURPHY, Pennsylvania
JIM MATHESON, Utah                   MICHAEL C. BURGESS, Texas
G.K. BUTTERFIELD, North Carolina     MARSHA BLACKBURN, Tennessee
CHARLIE MELANCON, Louisiana
JOHN BARROW, Georgia
BARON P. HILL, Indiana

                                 ______

                           Professional Staff

                 Dennis B. Fitzgibbons, Chief of Staff

                   Gregg A. Rothschild, Chief Counsel

                      Sharon E. Davis, Chief Clerk

               David L. Cavicke, Minority Staff Director

                                  (ii)
              Subcommittee on Oversight and Investigations

                    BART STUPAK, Michigan, Chairman
DIANA DeGETTE, Colorado              ED WHITFIELD, Kentucky
CHARLIE MELANCON, Louisiana              Ranking Member
    Vice Chairman                    GREG WALDEN, Oregon
HENRY A. WAXMAN, California          MIKE FERGUSON, New Jersey
GENE GREEN, Texas                    TIM MURPHY, Pennsylvania
MIKE DOYLE, Pennsylvania             MICHAEL C. BURGESS, Texas
JAN SCHAKOWSKY, Illinois             MARSHA BLACKBURN, Tennessee
JAY INSLEE, Washington               JOE BARTON, Texas (ex officio)
JOHN D. DINGELL, Michigan (ex 
    officio)
  
                             C O N T E N T S

                              ----------                              
                                                                   Page
Hon. Bart Stupak, a Representative in Congress from the State of 
  Michigan, opening statement....................................     1
Hon. Ed Whitfield, a Representative in Congress from the State of 
  Kentucky, opening statement....................................     3
Hon. John D. Dingell, a Representative in Congress from the State 
  of Michigan, prepared statement................................     4
Hon. Joe Barton, a Representative in Congress from the State of 
  Texas, prepared statement......................................     5
Hon. Frank Pallone Jr., a Representative in Congress from the 
  State of New Jersey, prepared statement........................     6
Hon. Gene Green, a Representative in Congress from the State of 
  Texas, opening statement.......................................     7
Hon. Michael C. Burgess, a Representative in Congress from the 
  State of Texas, opening statement..............................     8
Hon. Jan Schakowsky, a Representative in Congress from the State 
  of Illinois, opening statement.................................    10
Hon. Tim Murphy, a Representative in Congress from the State of 
  Pennsylvania, opening statement................................    11
Hon. Diana DeGette, a Representative in Congress from the State 
  of Colorado, opening statement.................................    12
    Prepared statement...........................................    13

                               Witnesses

Len Paulozzi, M.D., medical epidemiologist, Division of 
  Unintentional Injury Prevention, National Center for Injury 
  Prevention and Control, Centers for Disease Control and 
  Prevention, U.S. Department of Health and Human Services.......    14
    Prepared statement...........................................    16
H. Westley Clark, M.D., Director, Center for Substance Abuse 
  Treatment, Substance Abuse and Mental Health Services 
  Administration, U.S. Department of Health and Human Services...    36
    Prepared statement...........................................    38
Andrea M. Trescot, M.D., president, American Society of 
  Interventional Pain Physicians; director, Pain Fellowship......    60
    Prepared statement...........................................    62

                           Submitted Material

``What is a Pill Mill?'' CBS News, June 1, 2007..................    97
Letter of October 23, 2007 from Charles M. Grudem, M.D., to 
  Andrea Trescot, M.D............................................    98
Letter of Gayle B. Harrell, State representative, Florida House 
  of Representatives.............................................   101
Subcommitte exhibit binder.......................................   102


  NASPER: WHY HAS THE NATIONAL ALL SCHEDULES PRESCRIPTION ELECTRONIC 
                  REPORTING ACT NOT BEEN IMPLEMENTED?

                              ----------                              


                      WEDNESDAY, OCTOBER 24, 2007

                  House of Representatives,
      Subcommittee on Oversight and Investigations,
                          Committee on Energy and Commerce,
                                                    Washington, DC.
    The subcommittee met, pursuant to call, at 10:05 a.m., in 
room 2123 of the Rayburn House Office Building, Hon. Bart 
Stupak (chairman) presiding.
    Members present: Representatives DeGette, Green, 
Schakowsky, Pallone, Whitfield, Murphy, and Burgess.
    Staff present: Kristine Blackwood, Joanne Royce, Scott 
Schloegel, Kyle Chapman, Alan Slobodin, and Karen Christian.

  OPENING STATEMENT OF HON. BART STUPAK, A REPRESENTATIVE IN 
              CONGRESS FROM THE STATE OF MICHIGAN

    Mr. Stupak. The subcommittee will come to order. Today we 
have a hearing on ``NASPER: Why Has the National All Schedules 
Prescription Electronic Reporting Act Not Been Implemented?'' 
Each Member will be recognized for a 5-minute opening 
statement. I will begin.
    More than 2 years ago, with wide-spread support in both the 
House and Senate, Congress passed the National All Schedules 
Electronic Reporting Act, otherwise known as NASPER. NASPER 
established a grant program at the Department of Health and 
Human Services to foster the development of prescription drug 
monitoring programs in every State. These drug monitoring 
programs will provide a safe, comprehensive, and balanced 
approach to stop the growing epidemic of prescription drug 
abuse by detecting and preventing doctor shopping for addictive 
drugs.
    I was pleased to join with my good friends, Ed Whitfield, 
ranking member of this subcommittee, full committee Chairman 
John Dingell, Ranking Member Mr. Barton, as well as Congressman 
Pallone, chairman of our Health Subcommittee, to work and have 
Congress pass this comprehensive program to provide the tools 
necessary to the physicians, pharmacists, and law enforcement 
for fighting prescription drug abuse. In passing NASPER, 
Congress recognized that prescription drug abuse cannot be 
fought only by law enforcement. It is not enough to simply 
prosecute pill mills and drug addicts to solve this complex 
problem. Identifying the pill mills and prosecuting dealers 
occurs after the pill pushers have been in business for months 
or years, spreading the devastation to the addicts, their 
families and communities.
    Congress passed NASPER because we understand that, in 
addition to putting drug dealers behind bars, we must ensure 
that physicians, pharmacists, and public health officials have 
the resources they need to identify and stop drug addiction 
before it begins. NASPER would enhance that so physicians have 
immediate access to patients' prescription drug history. NASPER 
would give pharmacists the ability to thwart doctor shopping by 
patients and drug dealers. NASPER would ensure that patients 
are not being over-prescribed pain medicine or taking dangerous 
combinations of prescription drugs. NASPER would ensure that 
public health officials could review prescribing patterns, 
educate, and warn physicians about medication risk. At the same 
time, NASPER ensures that law enforcement will have access to 
prescription drug data to support their investigations and 
prosecutions.
    In short, NASPER recognizes that prescription drug 
addiction is both a law enforcement, medical, and a public 
health problem. Congress granted HHS oversight of the NASPER 
Program because we believe that the program fits best within 
HHS's public health mission. NASPER calls upon the Secretary of 
HHS to issue regulations with public input to ensure uniformity 
among the States' prescription drug monitoring programs. If 
drug monitoring programs receive real-time and uniform 
electronic data, States can share critical drug data abuses 
while effectively protecting patient privacy. The NASPER 
Program will benefit from HHS expertise and experience in 
addition to prevention, treatment, and medical privacy law, 
health information, and e-prescribing technology. Moreover, 
NASPER can be integrated with the prescription drug benefit 
programs run by Medicaid and Medicare programs and help the 
Food and Drug Administration to monitor the post-market effect 
of prescription drugs.
    This administration has failed to provide any funding to 
implement the NASPER Program. Instead, the administration has 
promoted and funded a drug addiction program at the Department 
of Justice that was never authorized by Congress, a program 
that emphasizes the law enforcement aspect of prescription drug 
epidemic at the expense of public health concerns.
    The purpose of today's hearing is to determine why the will 
of Congress has been ignored. We will hear from three 
distinguished witnesses this morning. First we will hear from 
Dr. Leonard Paulozzi. Am I saying that correct, sir?
    Dr. Paulozzi. It is Paulozzi.
    Mr. Stupak. Paulozzi, from the Centers of Disease Control 
and Prevention in Atlanta, and he is a nationally recognized 
expert on prescription drug abuse trends. Dr. Paulozzi's 
testimony will provide troubling evidence that the epidemic of 
prescription drug abuse is getting worse, not better. Next, we 
will hear from Dr. Westley Clark, the Director of the Center 
for Substance Abuse Treatment at the Substance Abuse and Mental 
Health Services Administration of HHS. Dr. Clark is an expert 
in addiction treatment and prevention and leads the Agency's 
effort to provide effective and accessible treatment to 
Americans with addictive disorders. Our third witness will be 
Dr. Andrea Trescot, the president of the American Society for 
Interventional Pain Physicians, or ASIPP. In addition to her 
leadership role with ASIPP, Dr. Trescot is a Director of Pain 
Fellowship Program at the University of Florida. Dr. Trescot 
will provide the physician's perspective on the importance of 
implementing NASPER.
    Let me advise members that we are setting up a meeting with 
the Office of Management and Budget. This subcommittee 
requested that OMB testify before us to gain a better 
understanding of the administration funding goals. 
Unfortunately, Director Nussle could not make it, but he will 
be meeting with us at 3:30 p.m. Thursday. Let me be clear. This 
subcommittee and this committee are committed to carrying out 
the NASPER Program, and we hope the administration will join 
us. I thank the witnesses for appearing today, and I look 
forward to their testimony.
     Next, let me yield to my friend and one of the advocates 
of the NASPER Program, Mr. Whitfield from Kentucky, for an 
opening statement, please.

  OPENING STATEMENT OF HON. ED WHITFIELD, A REPRESENTATIVE IN 
              CONGRESS FROM THE STATE OF KENTUCKY

    Mr. Whitfield. Chairman Stupak, thank you very much. I want 
to thank you for convening this important hearing.
    Back in 2005, many members of the Energy and Commerce 
Committee co-sponsored legislation, the NASPER legislation, 
which was passed by the House of Representatives under the 
suspension calendar, and about 3 days later passed the U.S. 
Senate, and then President Bush signed NASPER into law on 
August 11, 2005. NASPER was the product of strong bipartisan 
support. It was passed by the committee by voice vote after 
hearing testimony about the epidemic of prescription drug abuse 
in this country. The members of this committee and the House 
and Senate felt compelled to create a Federal prescription drug 
monitoring program to reinforce the State programs and to 
ensure that these programs were interoperable, that information 
could be shared, that the NASPER law also provided a basic 
guideline and had mandates in it so that every program had to 
meet certain specifications. It allows physicians to obtain 
information about their patient so that they can identify and 
treat a possible addiction. It also allows law enforcement to 
access prescribing information so that they can build 
investigations against doctors and patients who abuse the 
healthcare system by improperly prescribing or obtaining 
prescription drugs.
    Yet almost 2 years after NASPER was signed into law by the 
President, not a single dollar has been requested by the 
administration, by OMB, and I am not sure, Dr. Clark, that even 
HHS has asked for any dollars for this program when you 
compiled your budget requests and sent them to OMB. As Chairman 
Stupak said, we have talked to OMB, we invited OMB to come and 
testify, and they said they would like to meet with us 
privately on this issue. But I would like to stress what 
Chairman Stupak said. The only program in existence today is a 
non-authorized program that the Appropriations Committee 
decided that they would fund without any hearings, without any 
checks and balance on the system. They simply provided the 
money, and the first year after NASPER was signed, we all sat 
in a room, appropriators and Energy and Commerce people, and 
Chairman Barton was very emphatic in that meeting that NASPER 
was going to be funded. We agreed to fund NASPER to the tune of 
$5 million, and the Department of Justice system was funded for 
$5 million, but due to the continuing resolution, funding for 
NASPER was never appropriated. And we asked Chairman Dingell to 
get involved in this issue because it does go to the 
jurisdiction of this committee. We have jurisdiction over this 
issue, but more important than that, more important than 
jurisdiction, is which program is the best program?
    The DOJ program is focused on law enforcement. NASPER is 
focused on providing information for physicians so that they 
can best treat their patients, who may be suffering from drug 
addiction, and we know that drug addiction is a serious problem 
around the country. And I know that Dr. Paulozzi will talk 
about that in his testimony. And I also noted that, Dr. Clark, 
we are glad you are here today, but I noticed in your testimony 
you don't mention anything about NASPER. You are talking about 
the DOJ program, but the DOJ program was not authorized by 
anyone, and appropriators don't have jurisdiction over the 
program. We have jurisdiction.
    And so I look forward to the testimony today, because this 
is a program passed by Congress, signed by the President, and 
someone has the responsibility and obligation to fund this 
program, not because this committee passed it, but because it 
is the best program, the one most likely to succeed. So, with 
that, Mr. Chairman, I will yield back the balance of my time.
    Mr. Stupak. I thank the gentleman. I ask for unanimous 
consent to enter Chairman Dingell's statement in the record, 
and that statement of all members will be entered in the 
record, whether they appear or if they just provide a 
statement.
    [The prepared statements of Messrs. Dingell, Barton, and 
Pallone follow:]

    Prepared Statement of Hon. John D. Dingell, a Representative in 
                  Congress from the State of Michigan

     Mr. Chairman, thank you for holding this hearing on 
implementation of the National All Schedules Prescription 
Electronic Reporting Act (NASPER).
     The NASPER legislation was passed by the 109th Congress 
and signed into law by the President in 2005. Although the 
NASPER Program was enacted 2 years ago, this administration has 
done virtually nothing to implement it and has failed to 
include any money for the program in its annual budgets. It is 
vitally important to our system of government that when 
Congress establishes national policy by passing laws, those 
laws are not simply ignored by the executive branch. Today, I 
hope we learn more about the benefits of this program as well 
as the reason for the administration's failure to seek funding 
for it.
     In order to solve the problem of prescription drug abuse, 
we need a multi-pronged approach. We cannot solve the complex 
problems associated with abuse and addiction with criminal 
enforcement alone. We need to enlist physicians, pharmacists, 
and other healthcare professionals in the fight. A robust, 
nationwide system of prescription drug monitoring programs will 
help medical professionals prescribe responsibly. Strong 
monitoring systems can allow physicians to promptly identify 
patients at risk for addiction and get them into treatment, and 
avoid patients who are ``doctor shopping'' to feed their own 
addiction or to sell their drugs to other addicts.
     NASPER would provide a strong monitoring tool to help not 
only law enforcement but also the medical community stop the 
``pill-pushing'' and ``doctor shopping'' that has devastated so 
many of our communities over the last decade. Especially in 
rural areas, where isolated physicians and pharmacies can 
easily be manipulated by addicts who travel from community to 
community to get their fix for illegal pharmaceuticals, NASPER 
would ensure that these healthcare providers know what drugs 
their patients have recently obtained or have tried to obtain 
in other communities including those across State lines.
     As you know, Mr. Chairman, our State of Michigan has a 
strong prescription drug-monitoring program. Ninety-five 
percent of the requests Michigan's program receives are from 
doctors and pharmacists seeking to ensure that patients are 
getting the medicine they need for genuine medical purposes, 
not medicine that will be used for illicit purposes. I am 
interested in hearing from our witnesses how Michigan's program 
compares with others around the Nation and how NASPER could 
enhance these programs.
     I commend Ranking Member Whitfield for his leadership on 
this issue, and I thank our witnesses for their testimony 
today.
                              ----------                              


  Prepared Statement of Hon. Joe Barton, a Representative in Congress 
                        from the State of Texas

     Thank you, Chairman Stupak and Ranking Member Whitfield, 
for holding this hearing on the status of the National All 
Schedules Prescription Electronic Reporting Act.
     NASPER is the result of broad, bipartisan and bicameral 
cooperation of the kind that we don't see much anymore. It 
passed this committee over 2 years ago by voice vote. The House 
passed it as a suspension bill, and the Senate passed it by 
unanimous consent. The President signed NASPER into law on 
August 11, 2005.
     NASPER was so successful as legislation because its 
purpose was so transparent and simple. The law created grants 
to help fund state prescription drug monitoring programs. The 
idea, as I noted 2 years ago when we passed NASPER, is that 
States be able to work with each other to stop the abuse of 
prescription drugs. NASPER starts the States on the road to 
cooperation by making certain that they each collect the same 
information. So instead of 50 separate monitoring programs with 
50 different data sets that don't jibe, States collect the same 
data and then share it. Real interoperability means we can 
detect illicit prescription-drug operations when the drug 
dealers shift across state lines. Without NASPER, 
unfortunately, drug abusers and their dealers can still 
prescription-shop in some States because some information isn't 
being shared. That's a problem, and we're here today to start 
fixing it.
    The Energy and Commerce Committee was also concerned about 
protecting the privacy of Americans whose information is held 
in the prescription drug databases. NASPER establishes strict 
criteria governing the use and disclosure of the information 
that states must meet in order to receive funding. Without 
NASPER, there are no minimum standards to protect the personal 
information held in prescription drug monitoring program 
databases.
    Despite these positive features, NASPER has not yet been 
funded. Although the President signed the bill, funding for 
this important program was not included in the President's 
budget. On January 10, 2006, several of us on the committee--
including Chairman Dingell, Mr. Whitfield, Mr. Stupak, Mr. 
Deal, and Mr. Pallone--wrote to then-director of the Office of 
Management and Budget Joshua Bolton, requesting the inclusion 
of $15 million in the administration's fiscal year 2007 budget 
for NASPER. To get NASPER launched, there has to be a budget 
request. At the February 6, 2007 full committee hearing on the 
HHS fiscal year 2008 budget, HHS Secretary Michael Leavitt 
testified that HHS supported the program, but that OMB decided 
not to include a budget request for it. I understand that we 
have not even received a reply to the January 10, 2006 letter.
    We had hoped to have a witness from the Office of 
Management and Budget here today to explain OMB's reluctance. 
Instead, I understand that OMB Director Jim Nussle has agreed 
to meet with Mr. Whitfield and other members of this 
subcommittee in the near future to discuss the status of 
NASPER's funding. I hope that Director Nussle can finally 
answer the question we put to two of his predecessors: Why 
hasn't the administration included a request to fund NASPER in 
its budgets? The problem of prescription drug abuse doesn't 
seem to be curing itself, and it isn't as if the issue is 
either partisan or even mildly controversial. We are here today 
to find out why nothing has happened.
    I am committed to ensuring that NASPER is funded. Last 
year, I raised a point of order to the appropriations bill for 
the Commerce, Justice, and State Departments because funding 
was included in that bill for an unauthorized prescription drug 
monitoring program at the Justice Department while no 
appropriations were provided for NASPER. I trust now that they 
are in the majority, Committee Chairman Dingell and 
Subcommittee Chairman Stupak will continue to make this 
committee's concerns about the lack of funding for NASPER known 
to our colleagues here in the House and to the Administration. 
I suspect I can count on it, in fact.
     Thank you, again, Chairman Stupak and Ranking Member 
Whitfield. I yield back the balance of my time.
                              ----------                              I1
1/


  Prepared Statement of Hon. Frank Pallone, Jr., a Representative in 
                 Congress from the State of New Jersey

    Thank you, Mr. Chairman, for holding this hearing and 
allowing me to participate. I am pleased to be here today to 
discuss the importance of prescription drug monitoring. The 
bipartisan legislation we are reviewing today was signed into 
law by President Bush in 2005, But today, more than 2 years 
later, it has still not been funded. As the only program 
authorized in statute to assist states in combating 
prescription drug abuse, it is crucial that we work to ensure 
the Act receives the funding needed for implementation.
    At the time this legislation was passed, members on both 
sides of the aisle agreed that rampant prescription drug misuse 
and abuse was a growing problem. And now, 2 years later, it is 
still a growing problem. In fact, the diversion of prescription 
drugs is one of the fastest growing areas of drug abuse in our 
Nation today. It is a problem that is blind to geographic 
regions, blind to age, and blind to income-levels. And 
according to the data, it affects 9 million Americans.
    In my home State of New Jersey alone, 4.1 percent of our 
residents have abused prescription drugs in the past year. The 
per capita retail distribution of the pain medication oxycodone 
increased 181 percent between 2000 and 2005. For hydrocodone, 
another pain medication, it increased 66 percent during that 
same timeframe.
    Some States have already begun developing the means to stop 
this escalating trend, and Congress agreed back in 2005 that 
the NASPER Act was the best way to aid States in their efforts 
to ensure that prescription drugs are only being used for 
medical purposes, in the correct way, and that they are not 
getting into the hands of people who would abuse them.
    The solution presented through NASPER is to create a better 
monitoring and tracking system for prescription drugs. And 
studies have shown these types of programs to be very 
effective. The five States with the lowest number of oxycodone, 
specifically OxyContin prescriptions per capita, have long-
standing prescription monitoring programs and report no 
significant prescription drug diversion problems. While at the 
same time, the five states with the highest number of OxyContin 
prescriptions per capita do not have prescription monitoring 
programs and have reported severe abuse problems.
    This data strengthens the argument that health care 
practitioners and pharmacists desperately need electronic 
monitoring systems to ensure that they are prescribing and 
dispensing Schedule II, III, and IV Controlled Substances that 
are medically necessary. And NASPER assists them in this area.
    As passed in 2005, NASPER would provide grants to help 
States develop or expand a prescription drug-monitoring program 
that has the ability to communicate with monitoring programs in 
other States. Any Controlled Substance II, III, or IV that is 
prescribed would be electronically reported by the physician or 
pharmacist to the State's primary monitoring authority. Upon 
certified request, physicians and law enforcement can access 
the information in these databases, in an effort to prevent 
prescription drug addiction and to crack down on bad actors who 
are contributing to the problem.
    Without these interconnected databanks, practitioners and 
pharmacists have no way of knowing with any certainty whether a 
particular patient has received the same drug or another 
incompatible controlled substance already from another 
practitioner.
    This is particularly troubling in light of the fact that 
physicians are increasingly more hesitant to prescribe these 
medications out of fear that they will be the ones to take the 
fall if a patient is in fact ``doctor shopping'' and abusing 
these substances. More and more patients have to suffer from 
intense pain because doctors are overly cautious in prescribing 
the medications they need. A program like the one we are 
discussing today would protect the innocent provide them with 
the information they need to make the correct decisions for 
their patients.
    The NASPER bill passed Congress and was signed into law in 
August 2005. Thanks to its passage, I firmly believe that we 
will move one step closer in providing a strong and effective 
approach to addressing prescription drug abuse and crime. But 
our fight is not over, just because the bill has passed. Now we 
need to get the program funded so we can provide the necessary 
money to States.
    Because of the strict timetable set forth in NASPER, it is 
vital that funding be included in fiscal year 2008 to ensure 
that HHS is able to promulgate regulations and seek public 
input, thereby allowing grants to be awarded this year.
    My colleague from Kentucky, Ed Whitfield, and I are busy 
working towards achieving that goal. We have sent a letter to 
appropriators requesting $15 million in funding for NASPER in 
fiscal year 2008. I have the letter here, Mr. Chairman, and 
would like to submit it for the record. We have also been 
speaking with members of the appropriations committee urging 
them to fulfill our request.
    And I would like to thank you again, Mr. Chairman, for 
having this very important hearing today. I am hopeful that we 
will be able to get this program funded this year. I would also 
like to thank all the witnesses for joining us and I look 
forward to your testimony.
                              ----------                              

    Mr. Stupak.With that, next I would move to Mr. Green for 
opening statement, please.

   OPENING STATEMENT OF HON. GENE GREEN, A REPRESENTATIVE IN 
                CONGRESS FROM THE STATE OF TEXAS

    Mr. Green. Thank you, Mr. Chairman, for ordering this 
hearing on prescription drug monitoring programs and the NASPER 
Program, which Congress enacted in 2005. High-ranking member 
Mr. Whitfield was the author of the National All Schedules 
Prescription Electronic Reporting Act, and I was proud to be a 
co-sponsor and support it when it went through both our 
committee and both the 108 and 109th Congress. The need for 
NASPER is clear to us, being on both the law enforcement level 
and a drug safety level. With State prescription drug 
monitoring programs sporadic and not interoperable, it was 
relatively easy for individuals who abuse prescription drugs to 
doctor shop for controlled substances or obtain the 
prescription drugs illegally with little detection from 
physicians or law enforcement.
    The Texas prescription drug monitoring program, called the 
Texas Prescription Program, was established more than 25 years 
ago, in 1981. Each year the Texas Prescription Program collects 
3.3 million prescriptions and monitors Schedule II prescription 
drugs. During the first year of the Texas Prescription Drug 
enactment, the number of Schedule II prescriptions filled in 
the State fell by 52 percent. The program helped the State 
crack down on pill mills and forged prescriptions, but it is 
clearly a law enforcement program and housed at the Texas 
Department of Public Safety. Without question, prescription 
drug monitoring programs offer significant benefits for law 
enforcement. They should go hand in hand with the drug safety 
and public health benefits. It is disturbing that the 
administration doesn't recognize these dual needs and implement 
the NASPER Program.
    Mr. Whitfield, this committee purposely housed NASPER with 
the Department of HHS to strike the appropriate balance between 
law enforcement activities and public health safeguards. In 
fact, the criteria for grant awards ensured a certain level of 
interoperability, timely reporting by pharmacies, and 
assurances for patients of privacy. By giving physicians access 
to the data compiled by prescription drug monitoring programs, 
NASPER would also help physicians coordinate care and reduce 
the number of contraindicated drugs prescribed to patients. The 
administration's refusal to implement this program suggests it 
is only interested in law enforcement aspects of prescription 
drug monitoring programs.
    Secretary Leavitt supported this conclusion when he 
appeared before this committee earlier this year and cited 
OMB's decision to review these programs as law enforcement 
tools, while the administration's synthetic drug control 
strategy and drug monitoring program is at the Department of 
Justice. The problem is, neither the administration's synthetic 
drug control strategy nor the DOJ grant program ever has been 
authorized by Congress. My State received the welcomed grant 
funding through the DOJ programs, but the DOJ programs only 
provide half a loaf. Within the DOJ program, there is no real 
strategy for interoperability, which is critical if we want to 
stop folks from hopping across State lines to obtain 
prescription drugs illegally and escape detections from their 
home State monitoring programs. The DOJ programs also have none 
of the safeguards for patient privacy and pay little to no 
attention to public health ramifications.
    Like my colleagues, I wish OMB Director Nussle would have 
appeared before us today and explained the administration's 
rationale for failing to implement NASPER. However, I am 
pleased that he has agreed to meet with our Chair and ranking 
member to discuss the important issue. I hope that Mr. Nussle, 
as a former member of this chamber, will be able to understand 
the frustrations we feel when the administrations ignore 
Congressional intent. And I would like to thank the Chair and 
the ranking member for holding this hearing and needed 
oversight over the administration's inaction on this issue and 
shed light on the administration's missed opportunity to 
address the problem of prescription drug abuse in an effective 
manner. And again, I am glad our witnesses are here.
    Mr. Chairman, I yield back my time.
    Mr. Stupak. Thank you, Mr. Green. Mr. Burgess, for an 
opening statement, please.

OPENING STATEMENT OF HON. MICHAEL C. BURGESS, A REPRESENTATIVE 
              IN CONGRESS FROM THE STATE OF TEXAS

    Mr. Burgess. Thank you, Mr. Chairman, and I appreciate very 
much you holding this hearing today. Back in my home State of 
Texas, in the city of Dallas, the Dallas Morning News ran a 
series of several articles, 2003, 2004, 2005, on a physician 
who ran a pill mill. And it seems that everyone knew about the 
pill mill. He didn't make appointments, but he saw a lot of 
patients, and the patients were seen, I guess you would call it 
kind of a modified wave method of making appointments. The 
patients would sleep in the parking lot so they would be the 
first in line to get in the door the next day, and in fact 
sometimes the clinic had to hire off-duty police officers to 
kind of keep order in the parking lot before the clinic opened. 
The doctor would see 200 patients a day. They were mostly 
Medicaid and Medicare beneficiaries. In fact, this office was 
the source for the largest single source of Diazepam 
prescriptions for Medicaid prescriptions in the State of Texas. 
Now, at least 11 of his patients died, and they died of drug 
overdoses or drug complications, and after a very long 
investigation, culminating just a few weeks ago, this doctor 
received probation. I think, had this program, had NASPER been 
up and running and functioning, I think he certainly could have 
been contained much earlier, and I think some patients and 
their families could have foregone some needless suffering, and 
perhaps we could have even avoided loss of life.
    Now, when NASPER was signed into law, August 11, 2005, it 
was the only congressionally authorized program to assist State 
prescription drug monitoring programs. The previous program 
established by the Department of Justice was created with a 
lack of adequate Congressional oversight and appropriate 
administration by the Justice Department. Both parties agreed 
that such a program should have strict guidelines and that 
Health and Human Services is better suited to administer such a 
program than the Department of Justice. So NASPER must be 
funded, especially to guard against scenarios such as this that 
has been well documented in my papers back home.
    Well, Chairman Stupak, I thank you and ranking member 
Whitfield for holding the appropriators accountable, and I join 
in asking them to make the Appropriations Committee aware and 
to fund this program.
    And NASPER could allow doctors to find out what medications 
a patient is currently taking and what he or she has taken in 
the past. Without a database in place for doctors to track 
patient history, doctors have no way of knowing who is really 
in pain and who is looking to abuse the system, and I speak of 
this with some authority because I was a practicing physician 
back in Texas for 25 years, and I certainly know. I got caught 
in similar situations. I do have some questions. I have some 
questions about how this is affected by our current HIPAA laws, 
and then, going further, how is the law that we recently 
passed, the Genetic Information Non-Discrimination Act, how is 
that going to affect the sharing of information, because that 
bill was fairly broadly constructed and I think may have more 
of an effect on this that will curtail the sharing of data. Now 
a database is extremely powerful, extremely powerful in helping 
to manage a patient's care and helping to provide information 
to caregivers about a patient's status.
    We had a situation in Dallas right after Hurricane Katrina 
landed in New Orleans 2 years ago. A lot of folks were taken 
from the Superdome in Louisiana and delivered to the parking 
lot outside Reunion Arena in Dallas. Many of these people were 
patients who were on multiple medications. Many of them had 
been without their medications for several days, and some were 
just a few steps away from getting into serious trouble with 
their underlying illness. One of the chain pharmacies set up a 
mobile unit right outside Reunion Arena, and doctors were able 
to quickly access the database, get information about the 
patients. Obviously Charity Hospital didn't have electronic 
medical records up online, but this data was available to the 
doctors who were receiving those patients and triaging those 
patients in the parking lot of Reunion Arena, and within a very 
short period of time were able to accommodate those patients' 
needs. And I think out of the many, many thousands of people 
who were transferred from New Orleans to Dallas, only a few 
required hospitalization, because they got timely treatment and 
timely recognition on the night of their arrival. So it just 
underscores how powerful a database can be if used 
appropriately.
    Mr. Whitfield alluded to how important it is to have 
interoperability of databases, and I certainly think that is 
key if we are going to have two side-by-side systems. Clearly 
they need to be able to communicate with each other in 
efficient fashion. But realistically if we could have a single 
system that worked and was funded, I think that is the 
preferable route to go.
    With that, Mr. Chairman, I will yield back the balance of 
my time.
    Mr. Stupak. Thank you. Next opening statement, Ms. 
Schakowsky, please.

 OPENING STATEMENT OF HON. JAN SCHAKOWSKY, A REPRESENTATIVE IN 
              CONGRESS FROM THE STATE OF ILLINOIS

    Ms. Schakowsky. Thank you, Mr. Chairman. This is an 
important hearing for a couple of reasons. First, we all know 
that prescription drug abuse is rising and that accidental 
deaths from overdose have increased dramatically. But in 
addition, we know that over 2 years ago this Congress passed, 
and the President signed into law, aimed at fighting this 
growing problem. And yet to date, as people have said, but I 
think it bears repeating, no funds have been included in the 
President's budget for the implementation of this bipartisan 
bill, the NASPER.
    Without a doubt, there is a need for a tool to reduce 
prescription drug abuse. For many of our communities, this is 
an ever-growing problem that has resulted in the death of too 
many friends and neighbors and family members. According to 
this committee's records, when HHS Secretary Michael Leavitt 
testified before this committee on the President's 2008 budget, 
he stated that the Department supported the program and that it 
was a program that he would gladly administer. Yet, when 
pressed further, he deferred to the OMB, stating that it was up 
to them to make a final decision. And meanwhile, over the past 
several years, the Department of Justice has made annual grants 
to a number of States for the purpose of establishing or 
strengthening a prescription drug monitoring program. These 
grants have been supported both through Congressional earmarks 
and the President's budget requests, so the question I look 
forward to answering today is why NASPER has yet to be 
implemented or funded despite administration support for the 
prescription drug monitoring. Additionally, I look forward to 
hearing from our witnesses regarding what appears to be this 
administration's preference to house the prescription drug 
tracking program at a law enforcement agency, as opposed to the 
Department of Health and Human Services. I have concerns about 
what this means for patient privacy and preserving the 
relationship between patients and their physicians.
    It is also important that we examine the disadvantages of 
relying on the DOJ grant program, a competitive grant program 
which has yet to reach all States. Furthermore, State PDMPs 
have remained largely incompatible. If our best interests lay 
in exposing bad actors within the prescription drug arena, our 
system must be interoperable and attainable for all States. So 
I look forward to getting some answers from our witnesses, and 
I thank them all for being here today, and I yield back.
    Mr. Stupak. I thank the gentle lady. Mr. Pallone was here, 
and he had to step out, but unfortunately Mr. Pallone is not a 
member of the subcommittee, so he may not be allowed to make an 
opening statement but may be back to ask questions. But it 
should be noted, as I noted in my opening statement, it was Mr. 
Pallone, as ranking member of the Health Subcommittee, who 
helped push this legislation through and critical in getting it 
passed and signed into law. We appreciate his continued 
interest, and hopefully he will be able to make it back in time 
for questions. With that, Mr. Murphy, for an opening statement, 
member of the subcommittee.

   OPENING STATEMENT OF HON. TIM MURPHY, A REPRESENTATIVE IN 
            CONGRESS FROM THE STATE OF PENNSYLVANIA

    Mr. Murphy. Thank you, Mr. Chairman, and thank you for 
holding this important hearing. In particular because we are 
all very concerned about the abuse of prescription drugs, it 
should be noted that high school students in the United States 
and college students are declining in their abuse of illicit 
drugs for consecutive years, but there is an increasing level 
of the abuse of prescription drugs among youth and adults. And 
it is cause for concern, and it is an area that we need to 
closely monitor. And what we are considering today is a 
mechanism by which we can do this.
    I would like to quote briefly from an article that appeared 
in the Pittsburgh Post Gazette earlier this year, in March, 
where in reference to an interview with a Dr. Neil Capretto of 
the Gateway Rehabilitation Center in Pittsburgh, he said, 
``There has been a growing non-medical addictive use of 
prescription drugs, particularly opioid drugs like Oxycontin, 
codeine, morphine, Percocet, Vicodin, and Dilaudid. Opiates 
possess more properties characteristic of opioid narcotics like 
heroin and morphine but are not derived from opium poppy.'' He 
went on to say, ``The good news is, we are treating pain better 
than we did 10 years ago. The bad news is, there are more 
people abusing and misusing prescription drugs. Unfortunately, 
from our end, I am really afraid it is going to get worse 
before it gets better.''
    As of 2003, 6.3 million Americans used prescription drugs 
for non-medical purposes. In 2002 almost 30 million people had 
used prescription pain relievers for non-medical purposes. 
Prescription medications are now involved in close to 30 
percent of drug-related emergency room visits. The most recent 
monitoring, the Future Report from University of Michigan, 
found that 5.5 percent of all high school seniors abuse 
Oxycontin. Oxycontin abuse has increased 26 percent since 2002 
among 8th- and 9th- and 12th-graders. The abuse of prescription 
drugs cuts across gender, race, and virtually all groups.
    As we look at programs like NASPER, it is disappointing 
that it has not been funded, and that is why we are here today. 
The Appropriations Committee continues to fund a program out of 
DOJ that focuses solely on enforcement. Although we are pleased 
that DOJ has this program, and I don't necessarily have a 
problem with the DOJ program, but we have rules in place for a 
reason. Why should we fund an unauthorized program when we have 
an authorized program that accomplishes the same mission? With 
that said, we do agree on the mission, to prevent prescription 
drug abuse. In my many years of practice as a psychologist, I 
saw the wretched examples of drug abuse first-hand. And as we 
look at this, my questions will be, how can we make these 
programs work together? How can we make them be effective and 
efficient, not redundant or exclusive? How can we gather and 
share data and databases so we can work with law enforcement 
officials, we can work with drug treatment programs, and we 
will work with effective funding here in Congress?
    I don't believe there is anybody here who does not consider 
it a high mission of this Congress to make sure we do all we 
can to reduce prescription drug abuse and all drug abuse, for 
that matter. Because people understand how they can doctor 
shop, because databases are not clear, it stands as a barrier 
to enforcement. It stands as a barrier to treatment, and 
unfortunately it is the system that the drug abuser has figured 
out how to get around for now. We have to close those doors if 
we are going to help people. And again, reflecting on the 
statistics I read earlier, about 8th- and 9th- and 12th-
graders, it would be a real tragedy if we did not work to make 
this program work, to make this program and the Department of 
Justice program find a way of working together so that our goal 
of Justice and our goals in Congress of reducing and 
eliminating prescription drug abuse are met.
    I look forward to hearing the testimony of this hearing of 
how we can reach those goals, and I yield back my time, Mr. 
Chairman.
    Mr. Stupak. Thank you. Ms. DeGette, for an opening 
statement, please.

 OPENING STATEMENT OF HON. DIANA DEGETTE, A REPRESENTATIVE IN 
              CONGRESS FROM THE STATE OF COLORADO

    Ms. DeGette. Thank you, Mr. Chairman. Mr. Chairman, I will 
submit my full statement for the record, but I just want to say 
that a couple of months ago I read one of those articles that 
really opens your eyes in the New York Times Magazine--about 
patients who truly have chronic pain that affects their whole 
ability to conduct their lives. And these patients are really 
stuck in a whipsaw, because on the one hand they are trying to 
get medications that will help solve their pain, and there are 
many legitimate doctors now who say that patients like these 
really do need very high doses of pain medication. But these 
patients are caught because they are identified as abusers of 
these medications. And, at the same time then, you have people 
who really are abusers of these medications, and they are 
illegally obtaining these drugs. I think that NASPER would 
really help to bring some sense to this situation and allow the 
legitimate patients to get the drugs that they need, so that 
they can get pain relief while at the same time giving law 
enforcement the tools to track and identify both the abusers of 
these drugs and the physicians who are participating in some of 
the abuses. So I think it is a real shame on behalf of the 
patient and on behalf of law enforcement that we haven't funded 
NASPER, and I know that talks are continuing. I would hope that 
the administration would really put some funding behind this 
very important program.
    With that, Mr. Chairman, I will yield back.
    [The prepared statement of Ms. DeGette follows:]

Prepared Statement of Hon. Diana DeGette, a Representative in Congress 
                       from the State of Colorado

    Mr. Chairman, let me begin by thanking you for holding this 
hearing on the National All Schedules Prescription Electronic 
Reporting Act, a vital tool for ensuring public health and 
safety.
    Sadly, drug abuse has become an all-too-familiar issue, 
whether it be illicit drugs or drugs prescribed for pain 
relief. Chronic pain, for example, is a legitimate concern with 
legitimate treatment options, yet prescription pain killers are 
often abused. We need a way to allow patients access to such 
drugs when they are appropriate, while at the same time 
adequately controlling access and identifying patients who are 
at risk of addiction or are so-called ``doctor shoppers.'' We 
passed NASPER and signed it into law in 2005 for exactly these 
reasons, yet nothing has come of the program to date.
    NASPER would give law enforcement personnel access to drug 
monitoring data that relates to illegal prescribing, 
dispensing, or procurement of controlled substances, while also 
providing reliable data to doctors in the form of 
``prescription histories'' for their patients. Prescription 
histories not only help to identify doctor shoppers, but also 
help doctors identify patients who might at risk of addiction 
and would therefore be better-suited to an alternative, less 
addictive drug. Just as importantly, it would enable doctors 
and patients to avoid potentially deadly drug interactions that 
occur when patients see multiple doctors for different 
conditions but neglect to inform the doctor of other 
prescriptions they may be taking.
    NASPER does all this while providing privacy safeguards for 
patient protection and without placing pressure on doctors to 
avoid prescribing medicine that is legitimately needed.
    NASPER has the potential to be of immense value, yet 
because the Administration has failed to provide funding for 
it, it has not been able to help a soul.
    In fact, the administration has instead funded a different, 
unauthorized prescription drug monitoring program through the 
Department of Justice. This does not make much sense to me, 
especially given that the DOJ program lacks some of NASPER's 
key components.
    For example, the DOJ program lacks interoperability 
requirements that would allow States to share data--a key 
problem that we are seeing repeatedly with current Health 
Information Technology initiatives. NASPER, on the other hand, 
includes such interoperability provisions.
    Mr. Chairman, I would like to know why the administration 
is yet again dismissing Congress' authority--by not only 
failing to fund NASPER, but by instead funding an unauthorized 
program.
    I yield back the balance of my time.
                              ----------                              

    Mr. Stupak. Thank you. That concludes the opening 
statements by members of the subcommittee.
    We have our first panel before us. On our first panel we 
have Dr. Westley Clark, Director of the Center of Substance 
Abuse Treatment within the Department of Health and Human 
Services, Substance Abuse and Mental Health Services 
Administration, SAMHSA, as we call it, and Dr. Len Paulozzi, a 
medical epidemiologist at the Centers for Disease Control and 
Prevention. It is the policy of this subcommittee to take all 
testimony under oath. Please be advised that witnesses, under 
the rules of the House, have the right to be advised by counsel 
during testimony. Do either of you gentlemen wish to be advised 
by counsel during your testimony?
    Dr. Paulozzi. No.
    Dr. Clark. No.
    Mr. Stupak. Both indicate they do not. Therefore I will 
ask, since it is tradition to take testimony under oath, please 
rise, and raise your right hand to take the oath.
    [Witnesses sworn]
    Mr. Stupak. Let the record reflect both witnesses replied 
in the affirmative. You are now under oath. We will begin with 
your opening statements. Dr. Paulozzi, would you like to go 
first for 5 minutes for an opening statement, please, and thank 
you again for appearing.

   TESTIMONY OF LEN PAULOZZI, M.D., MEDICAL EPIDEMIOLOGIST, 
 DIVISION OF UNINTENTIONAL INJURY PREVENTION, NATIONAL CENTER 
FOR INJURY PREVENTION AND CONTROL, CENTERS FOR DISEASE CONTROL 
  AND PREVENTION, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

    Dr. Paulozzi. Good morning, Chairman Stupak, Ranking Member 
Whitfield, and distinguished members of the subcommittee. My 
name is Dr. Leonard Paulozzi, and I am a medical epidemiologist 
at the Centers for Disease Control and Prevention. I am here on 
behalf of the CDC Director, Dr. Julie Gerberding. My remarks 
will focus on drug poisoning involving prescription drugs in 
the United States as a public health problem. Can I have the 
second slide?
    [Slide]
    By way of background, this figure shows the leading causes 
of unintentional or, if you will, accidental injury death in 
the United States in 2004. The green bar is motor vehicle 
deaths. The yellow bar in the center is poisoning, which ranks 
as the second-leading cause of unintentional injury death, with 
approximately 20,000 deaths from this cause in the year 2004, 
of which 95 percent of these poisoning deaths are drug 
overdoses. Next slide.
    [Slide]
    The problem here is this upward trending line. This is drug 
poisoning death rates in the United States from 1970 through 
2004. You can appreciate the trend line and the dramatic 
increase in the 1990's and the first years of this decade. We 
can explain some of the earlier blips with black-tar heroin or 
crack cocaine, but the problem was explaining what happened in 
the later years of the 1990's. Next slide.
    [Slide]
    We did a study which looked at the death certificates to 
identify the drugs that were listed there as causing these 
deaths. We broke it down into three types, heroin in white, 
cocaine in yellow, and the red line at the top, pointed by my 
marker, is the opioid analgesic category. You can see it is 
going up dramatically. It outnumbers either heroin or cocaine 
by the year 2004. And this opioid analgesic category, of 
course, is the narcotic painkillers like Oxycontin and Vicodin 
that you have heard so much about. Next slide, please.
    [Slide]
    Again, this is the drug mortality death rate line that you 
saw before. I have paired it with opioid sales, shown here in 
green. These are sales per capita, shown from 1997 on. From 
1997 to 2004, the opioid sales increased six-fold, and the line 
closely tracks the death rate in drug poisoning. The other 
thing to note is that, 2005 and 2006 sales continued to go up, 
so we expect further increases in the drug poisoning death rate 
in 2005 and 2006. Indeed, preliminary information from 2005 
suggests that the death rate did rise in 2005. Next slide, 
please.
    [Slide]
    This shows the drug poisoning death rates in the United 
States. The dark States are those with the top third of death 
rates. I would like to point out that we have traditionally 
high rates in the Southwest. Louisiana, Maine, are also high, 
but we have a band of States, Appalachian States, from 
Tennessee to Pennsylvania, with some of the highest rates in 
the country. And as late as 1990, these same Appalachian States 
had some of the lowest rates in the country. So this has really 
affected rural States more than urban States in this particular 
prescription drug problem. Next slide.
    [Slide]
    Well, death certificates don't tell you circumstances of 
the death. So how do you know whether these are accidents of 
people taking too many pills, or are these abuse? We think that 
these are primarily related to misuse and abuse of prescription 
drugs, for three reasons. People dying of the prescription 
drugs are largely middle-aged males: the same groups who died 
of heroin and cocaine in earlier years. Surveys from SAMHSA 
have annually shown steady increases in prescription drug 
misuse, non-medical use rates in the United States. And lastly, 
studies done by medical examiners have found that the 
decendents from prescription drug deaths typically or commonly 
will have a history of substance abuse. Next slide.
    [Slide]
    How can the problem be addressed? Obviously this is a 
multi-factorial, complicated problem, and solving it depends 
upon input from multiple Federal and State agencies. CDC will 
continue to respond to this problem, as it has, through 
surveillance activities, epidemiological work, and through 
evaluation of potential interventions. In the next year, CDC 
will focus on a study of prescription drug deaths and poisoning 
victims. We will also start an evaluation of prescription drug 
monitoring programs, and we are working with the Association of 
State and Territorial Health Officials to look at State-
specific policy responses to this problem.
    Thank you for the opportunity to appear here today to make 
you aware of the serious health consequences of this growing 
misuse of prescription drugs in the United States, and I will 
be happy to answer any questions you may have.
    [The prepared statement of Dr. Paulozzi follows:]

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    Mr. Stupak. Thank you, Dr. Paulozzi. Dr. Clark, your 
opening statement, please, sir.

   TESTIMONY OF H. WESTLEY CLARK, M.D., DIRECTOR, CENTER FOR 
 SUBSTANCE ABUSE TREATMENT, SUBSTANCE ABUSE AND MENTAL HEALTH 
 SERVICES ADMINISTRATION, U.S. DEPARTMENT OF HEALTH AND HUMAN 
                            SERVICES

    Dr. Clark. Mr. Chairman, members of the subcommittee, my 
name is Dr. H. Westley Clark, and I am the Director of the 
Centers for Substance Abuse Treatment, within the Substance 
Abuse and Mental Health Services Administration, an agency of 
the U.S. Department of Health and Human Services. I am 
testifying on behalf of our Administrator, Terry Cline, Ph.D., 
who was not able to be here. I am a board certified 
psychiatrist with added qualification in addiction and 
psychiatry.
    According to SAMHSA's National Survey on Drug Use and 
Health, combined data from the reports from 2002 to 2006 
indicate that an average of 4.7 percent of persons age 12 and 
older, an estimated 12.6 million people, used prescription pain 
relievers non-medically in the 12 months prior to the survey. 
2006, 2.1 percent of persons age 12 and older used a 
prescription pain reliever non-medically in the month prior to 
the survey. Among persons 12 and older, 2.2 million initiated 
non-medical use of prescription pain relievers within the past 
year, and that is about the same as the estimated number of 
initiates for marijuana.
    Where do people obtain their drugs? The 2006 National 
Survey on Drug Use and Health also revealed where the people 
were obtaining their prescription drugs. Nearly 56 percent of 
the patients who had non-medical use of prescription pain 
relievers obtained the drugs free of charge from a friend or a 
relative, 19.1 percent from a single doctor; 14.8 percent 
bought or took them from a relative or a friend; 3.9 percent 
bought from a drug dealer or other stranger; 1.6 percent got 
them from more than one doctor; less than 1 percent reported 
getting them from the Internet; and 4.9 percent got them from 
other sources, including a fake prescription, or stole them 
from a doctor's office, clinic, or hospital pharmacy. As a 
result, it is clear that what we need is a coordinated 
response.
    The emerging challenge of prescription drug abuse and 
misuse is a complex issue that requires epidemiologic 
surveillance, distribution chain integrity, intervention, more 
research by both the private and the public sectors. We also 
need to be concerned about the issue of the appropriate use of 
prescription drugs. We know that there are some 75 million 
people who are suffering from severe pain. Some 50 million 
people suffer from chronic pain, and some 25 million people 
suffer from acute pain. So the Federal Government needs to work 
with medical partners, public health administrators, State 
legislatures, international organizations, are all needed to 
collaborate and cooperate through educational outreach and 
other strategies targeted to a wide swath of distinct 
populations, including physicians, pharmacists, patients, both 
intended and inadvertent, educators, parents, high school and 
college students, high-risk adults, the elderly, and many 
others. Outreach to physicians and their patients and 
pharmacists needs to be complemented by education, screening, 
intervention, and treatment for those misusing or abusing 
prescription drugs.
    Beginning fiscal year of 2002, Congress appropriated 
funding to the Department of Justice to support prescription 
drug monitoring programs. Since the inception of the Department 
of Justice program, called the Harold Rogers Prescription Drug 
Monitoring Program, this funding opportunity has resulted in 21 
States receiving new program grants and 13 States netting 
planning grants. There are now 25 States operating prescription 
drug monitoring programs and eight States with legislation in 
place to establish a program.
    In addition to the prescription monitoring programs of the 
DOJ, the Federal Government has a number of other activities 
involving prescription drugs. We are promulgating guidelines 
for the appropriate disposal of prescription drugs. These 
guidelines urge Americans to take unused, unneeded, or expired 
prescription drugs out of their original containers and dispose 
of them appropriately by mixing the prescription drugs with 
undesirable substances like coffee grounds or kitty litter to 
throw them away in the trash. We also are addressing the issue 
of prevention and treatment. We have drug-free communities, and 
on behalf of ONDCP we administer grants to communities across 
the country to form local anti-drug coalitions. We have spent 
$1.76 million for our substance abuse prevention and treatment 
block grant, $504 million in prevention and treatment 
discretionary grant, including our Access to Recovery, our ATR 
grant. We also have a screening and brief intervention grant. 
Furthermore, the National Institute of Drug Abuse has initiated 
a research program looking at the use of Buprenorphine for the 
treatment of prescription opioid abuse.
    As I stated earlier, the emerging challenge of prescription 
drug abuse and misuse is a complex issue that requires 
epidemiologic surveillance, distribution chain integrity, 
intervention, and more research by private and public sectors. 
It requires a concerted effort by many, and electronic 
monitoring systems are a key part of the response, along with 
treatment and prevention programs that include outreach and 
education. SAMHSA is committed to allowing programs to give 
States and the local authorities the flexibility they need to 
deal with the issue and meet the challenge. Our strategy of 
prevention and treatment is essential to that.
    Thank you for the opportunity to present this information 
to you.
    [The prepared statement of Dr. Clark follows:]

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    Mr. Stupak. Thank you, and thank you for your testimony. We 
will begin questions. We will go 5 minutes. If need be, we can 
go back and forth. Dr. Clark, in your testimony you never 
mentioned the NASPER Program. Why is that?
    Dr. Clark. At this particular point in time, the NASPER 
Program has not been funded, but the components of NASPER are--
we are actively engaged in addressing some of those components 
and working----
    Mr. Stupak. Well, if it hasn't been funded, how can you be 
actively engaged in addressing the components?
    Dr. Clark. We are involved in the issue of collecting data 
on prescription drug abuse.
    Mr. Stupak. Why didn't you fund NASPER or the program that 
you have then to help inform doctors of the problems of the 
prescription drug abuse?
    Dr. Clark. Well, we understand that the funding process is 
complex. It is my understanding that, through the 
appropriations process, Congress has chosen to fund these 
activities within DOJ and not HHS.
    Mr. Stupak. Well, as Mr. Whitfield said, there was $5 
million for the NASPER Program brought on approximately 2 years 
ago. What ever happened to that $5 million for the NASPER 
Program then?
    Dr. Clark. To my knowledge, we never got $5 million.
    Mr. Stupak. Has SAMHSA ever asked for money for the NASPER 
Program?
    Dr. Clark. I am not in a position to discuss the internal 
deliberations that occur in----
    Mr. Stupak. I am not asking for internal discussions. I am 
asking if you ever made a request of the appropriators for the 
NASPER Program. That is nothing internal. Did the Department 
ever ask for funding for the NASPER Program? That is a public 
statement. Did you ever do that?
    Dr. Clark. Asking for funds for specific programs is an 
internal process that we use, and we follow the internal 
processes to achieve that.
    Mr. Stupak. Why is the budget then published every year, if 
it is an internal process? It is a public process. The 
President sends his budget to Capitol Hill, and then we discuss 
whether or not to do it, whether or not to fund certain 
programs. Has the Department ever made a request to fund 
NASPER?
    Dr. Clark. To my knowledge, no.
    Mr. Stupak. From a public health perspective, what do you 
believe are the most important features of NASPER as 
distinguished from the unauthorized grant program at the 
Department of Justice?
    Dr. Clark. I think one of the most important things is that 
we want to be able to educate and inform practitioners, and we 
get that from the Department of Justice program. We want to 
make sure that there is this balance between the appropriate 
use of pain medications and the inappropriate use of pain 
medications. As I mentioned, there is some 75 million people 
who suffer from severe pain in the United States. So the 
concerted strategy that we are working with in the Federal 
Government, we believe, will assist us in addressing these 
issues in a cost-conscious environment.
    Mr. Stupak. Well, those two that you pointed out, to inform 
and educate the doctors who prescribe prescriptions, and also 
the use of pain medication, that is not found in the Rogers 
program in the Department of Justice, is it?
    Dr. Clark. I am not the best person to comment about the 
elaborate components of the Department of Justice programs.
    Mr. Stupak. Well, you testified on the Department of 
Justice program, so why can't you comment on the Department of 
Justice programs?
    Dr. Clark. I think the Department of Justice programs, in 
order to speak with the extreme authority, I think it would be 
best for the Department of Justice to comment. We do know that 
the Department of Justice is very much interested in advancing 
the public health component of theirs and not simply to aid in 
investigation and law enforcement. We know that they are----
    Mr. Stupak. Well, let me ask you this one, then. Let me ask 
you this. Last night at 8 o'clock, your Agency gave our 
investigators, 8 o'clock last night, a study required by the 
NASPER legislation. The study was supposed to be presented to 
Congress. That was supposed to be done 6 months after the bill 
was signed into law, which would have been August 2005, so 
early 2006 we should have received that report. We never saw 
the report until last night at 8 p.m. So why was this study a 
year and a half late? And when was this study completed?
    Dr. Clark. The study was released yesterday. It required 
extensive deliberation. We have discovered----
    Mr. Stupak. When was the study completed? I know you 
released it last night at 8 o'clock. When was it completed?
    Dr. Clark. The study was completed after it was approved, 
and I think part of the----
    Mr. Stupak. When was it completed, after it was approved?
    Dr. Clark. It was approved yesterday, sir.
    Mr. Stupak. So it took you 18 months to approve this study?
    Dr. Clark. Yes, sir.
    Mr. Stupak. How long did it sit in the Department, trying 
to get its final approval?
    Dr. Clark. I think the Department acted upon the report 
with dispatch and due deliberation, so it is not possible for 
me to comment on where it was after it left, because we have 
been exchanging comments and deliberations on it. So we have 
been actively involved in addressing the specifics of the 
report.
    Mr. Stupak. So you are telling me under oath here today 
that you have been actively and specifically going over this 
report for the last 18 months?
    Dr. Clark. Well----
    Mr. Stupak. Isn't the real answer was, you knew you were 
called up before this committee, so therefore you released your 
report last night? You haven't been actively engaged in this 
report. I can tell that just by looking at the report we saw 
last night, and I am reminding you, you are under oath. I am 
not trying to give you a bad time, but when we ask for things 
and you come here and you say you have been actively engaged in 
this thing for the last 18 months, studying it, and that is why 
it just got released last night, that is a bunch of bull. There 
is no other way to put it.
    Ms. DeGette. Mr. Chairman, if I may. I always say there is 
a good reason to have a hearing. You get so much information 
the minute you schedule the hearing, so this is just yet 
another example of it.
    Mr. Stupak. So, do you want to revise your answer on that 
last one? Or are you going to stick with actively engaged for 
the last 18 months?
    Dr. Clark. Oh, we were pursuing the report as expeditiously 
as we could, and the final deliberations of the report were 
completed when the report was released.
    Mr. Stupak. Mr. Whitfield for questions, please.
    Mr. Whitfield. Thank you, Chairman Stupak. Dr. Clark, you 
mentioned in responding to Mr. Stupak that HHS did not request 
any funding for NASPER. Is that correct?
    Dr. Clark. Yes, sir.
    Mr. Whitfield. And how was that decision made?
    Dr. Clark. Again, I am not at liberty to discuss the 
internal deliberations that occur every year during the 
preparation of our annual budget.
    Mr. Whitfield. Well, Secretary Thompson came and testified 
before this committee and said they supported NASPER, that it 
would be helpful to them in dealing with this problem. 
Secretary Leavitt came to this committee, testified to this 
committee, that NASPER would be helpful to them to solve this 
problem. And you are testifying this morning that you all did 
not request any money from OMB in your budget request. Is that 
correct?
    Dr. Clark. I am testifying that I am not at liberty to 
discuss the internal deliberations that occur----
    Mr. Whitfield. No, but I thought you said you did not 
request any funds for this program.
    Dr. Clark. In the public, published budget.
    Mr. Whitfield. All right. Now, Secretary Leavitt also said 
that it was OMB's decision not to fund this program. Can you 
make a comment on that?
    Dr. Clark. I will defer to Secretary Leavitt's comments.
    Mr. Whitfield. Well, the point that I would make is that it 
is quite obvious from the charts that Dr. Paulozzi has 
mentioned here and has shown us that the unintentional drug 
poisoning death rate continues to increase. And which would 
indicate that this program at DOJ maybe is not being as 
effective as it could be. Now, the reason that we were excited 
about NASPER was that the first prescription drug monitoring 
program in America was established in 1939 in California. And 
today there are 25 States that actually have operational 
programs. So, from 1939 until 2007, only 25 States have 
operating programs. NASPER mandated that States do certain 
things to get these programs up and operational, and as we 
stated earlier we had a lot of hearings on this issue. We 
didn't just run an appropriation bill, and put it in an earmark 
to establish a program. We had extensive hearings, a lot of 
testimony, and the thought was that this program is much more 
comprehensive, has guidelines and so forth, and would be much 
more effective. Now, let me ask you, has HHS or SAMHSA taken 
any steps to prepare for administering NASPER in the event that 
funding is provided?
    Dr. Clark. We have had internal discussions. We have worked 
with the medical groups. We have sent staff to the various 
meetings on prescription monitoring programs, and in fact we 
also have an internal working group on electronic health 
records, which we believe would be a component of this. We 
understand that electronic prescribing is a concept that is 
being promoted, and we believe that, should this issue mature, 
we would need to be able to address that. So, yes, we have been 
addressing some of the collateral issues that we think are 
essential to prescription monitoring.
    Mr. Whitfield. I might also say that we feel like in NASPER 
there are standards in there protecting patient privacy, which 
we think are superior to the DOJ program. I would also say that 
NASPER requires that dispensers like pharmacies report each 
dispensing of a controlled substance no later than one week 
after the date the drug was dispensed, and I don't think that 
is required on the DOJ program. And as far as interoperability 
of these programs, I mean, it is quite obvious that under the 
DOJ program not all these States are able to share information 
with each other. And I would just ask Dr. Paulozzi, how often 
do you all work with HHS? You are at the Centers for Disease 
Control. Do you all have a continuing dialogue with HHS on 
specific programs to address this unintentional drug death 
issue?
    Dr. Paulozzi. Well, Congressman Whitfield, we have had 
ongoing discussions with various staff at HHS. We worked with 
them very closely on the Fentanyl-heroin contamination issue of 
a year or two ago, and subsequently I have been keeping in 
touch with Dr. Hoffman at SAMHSA on various issues. But our 
conversations have not focused on the prescription drug 
monitoring program.
    Mr. Whitfield. Thank you. My time has expired.
    Mr. Stupak. Ms. Schakowsky, for questions, please.
    Ms. Schakowsky. I noticed that you said that you are 
testifying on behalf of your Administrator, Terry Cline, who 
was not able to be here. What I am also noticing as a 
consequence, you are not really able to talk about the funding 
issues, and I am disappointed in that because that is really at 
the center of what this hearing is about. We are trying to 
really get at why it is that NASPER has not been implemented 
within HHS. Do you think you are the best person, and, believe 
me, I am not challenging your role as a psychiatrist and your 
role at SAMHSA, but do you think you are really the best person 
that can explain what this committee is trying to get at?
    Dr. Clark. I think the committee is going to be meeting 
with the director of OMB, and you have already met with the 
Secretary on this topic, so I think those are the best people 
who can comment on this issue.
    Ms. Schakowsky. Well, we are going to do our best. The 
study that was presented to our staff last night, HHS states 
that there is no evidence of negative impact on patients' 
access to pain treatment, particularly access by children to 
medicines they need. That is under the current system, which is 
the DOJ grant program system. I wonder if you could elaborate 
on that and if there is a chilling effect on physicians because 
of the current system?
    Dr. Clark. One of the things that the report does 
acknowledge is that there is a paucity of general information. 
However, based on the modeling that was done, it does appear 
that the prescription modeling programs do have a chilling 
effect on practitioner behavior. One of the reasons a 
comprehensive strategy would be helpful, we are able to provide 
feedback to practitioners real time so that, in fact, you don't 
have children and adolescents denied care when that care is 
legitimate. Massachusetts----
    Ms. Schakowsky. But, can I just interrupt for 1 second? Do 
you think the fact that it would be this program, to the extent 
that it is implemented, with the prescription drug monitoring 
programs in selected States, but the fact that it is housed in 
a law enforcement agency, do you think that would add any 
additional negative impact?
    Dr. Clark. Our hope is that it would not.
    Ms. Schakowsky. What do you mean?
    Dr. Clark. Well, if in fact we are able to establish the 
linkages between the DOJ program, the HHS programs, and 
clinical practice, then we would not have a chilling effect.
    Ms. Schakowsky. Does the DOJ program provide for this 
coordination of agencies?
    Dr. Clark. I think the DOJ is attempting to achieve that.
    Ms. Schakowsky. So, so far there has not been any 
coordination. Do they coordinate with your agency?
    Dr. Clark. Not on a routine basis.
    Ms. Schakowsky. It appears that most States with these 
PDMPs, would the PDMP legislation choose to have their program 
in health agencies rather than in their law enforcement 
agencies? I wonder if you could comment on that.
    Dr. Clark. From the public health point of view, it appears 
that in a number of jurisdictions most of the people requesting 
information are actually prescribers. For instance, Kentucky's 
program, the group requesting reports tends to be, 92 percent 
were prescribers, three percent pharmacists, three percent law 
enforcement, 1 percent licensing board. So the issue is, how do 
we help physicians make proper decisions in the care of their 
patients? And we have got a system that allows for real-time 
exchange of information. We are able to facilitate that.
    Ms. Schakowsky. Thank you. I yield back.
    Mr. Stupak. Mr. Murphy, for questions, please.
    Mr. Murphy. Yes, Mr. Chairman, just a couple quick ones. 
This Department of Justice program, how long has it been going 
on, Dr. Paulozzi? My understanding is, about five years or so?
    Dr. Paulozzi. Are you referring to the Harold Rogers 
Program, Congressman?
    Mr. Murphy. Yes.
    Dr. Paulozzi. I am sorry. I don't really know when that 
program began.
    Mr. Murphy. My understanding, it was first funded around 
2002. When I think of the slides you were showing us, it 
appears that during that time we have seen some pretty dramatic 
increases in drug poisoning and death rates.
    Dr. Paulozzi. That is correct, Congressman.
    Mr. Murphy. And on your slide you were also indicating 
that--I am not sure if it is saying it is a correlation, or it 
is cause and effect that, with regard to the increase in the 
use of these opioids and other analgesics?
    Dr. Paulozzi. The trend lines parallel, which is consistent 
with a causal relationship. It certainly doesn't prove one.
    Mr. Murphy. And in the breakdowns in the testimony today, 
there is several factors that relatives may give the drugs 
away, some sell it, a small percentage are stolen from doctors' 
offices and prescriptions, but generally we trace it with these 
drugs. My question is this, is the Department of Justice 
program working?
    Dr. Paulozzi. Congressman Murphy, it is difficult to tell, 
without a formal evaluation of that process. It is hard to know 
what the rates would have been without interventions in 
prescription drug monitoring programs in selected States.
    Mr. Murphy. Sure. A good point. I appreciate that. What I 
am wondering here is, when I look back on some testimony that 
Secretary Leavitt had here, and it was actually in response to 
some questioning from my colleague, Mr. Whitfield, in reference 
to the NASPER Program he says, ``It is a program we support. It 
is a program we would gladly administer.'' He went on to say 
that it was OMB that recommended it be in the law enforcement 
program. My question is, to each of you, is there a value in 
doing the NASPER Program, even from the point of an armchair 
analyst, since it is not that it has been tried and found 
wanting, it has been unfunded and left untried, it seems to me. 
Am I correct in that assessment, that without the funding we 
don't know if it works, but we clearly know that the DOJ 
program is, during the time that that is in place, we are 
seeing an increase in these deaths? I would like both of you to 
answer that, too, if you could respond, please. You can point 
at each other. That is fine.
    Dr. Paulozzi. As I say, it is difficult to determine what 
the impact is of Harold Rogers or without a formal evaluation 
or rigorously-done evaluation to determine what the impact of 
NASPER could be. As I say, I think it is difficult to infer 
evidence of effectiveness or lack of effectiveness from the 
information we have here.
    Mr. Murphy. Will CDC be doing that kind of evaluation, to 
find out if it is working or has a value?
    Dr. Paulozzi. We actually do plan a study to look at the 
impact of the initiation of prescription drug monitoring 
programs of all kinds on the drug fatality rates in the States 
that implement them.
    Mr. Murphy. Dr. Clark?
    Dr. Clark. Should it be decided that NASPER should be 
funded, I think Secretary Leavitt's comments would answer your 
concerns. So I will defer to Secretary Leavitt's comments on 
this matter. Clearly, the Department is pursuing a number of 
initiatives which would envelope the NASPER issues and would 
allow an aggressive participation and monitoring of what is 
going on without sacrificing patient care.
    Mr. Murphy. Well, and I would hope we are all on the same 
page with this, so all I am trying to find is the most 
effective, most efficient way, and it seems to me when we team 
up with people who are involved with law enforcement and those 
who are involved with healthcare delivery monitoring, we could 
have some value here. I mean, when we are looking at even such 
things as electronic medical records, with which one can track 
who is doing the doctor shopping and getting duplicate drugs, 
it is a question that the physician can actually bring up with 
the patient in the confidential realm of the doctor's office, 
not necessarily waiting for the law enforcement officials, but 
to say, Mr. Jones, I think you have gone to several doctors 
here, and you are taking an awful lot of Oxycontin here. I am 
very concerned. And I don't know if the DOJ program allows that 
to happen. Is it? I mean, by design, does the DOJ program allow 
that? Do the physicians have access to that kind of information 
when they are seeing a patient?
    Dr. Paulozzi. My understanding is that there is nothing 
blocking their access to that information, but I would defer to 
people who know more about it than I do.
    Mr. Murphy. I am referencing, and there was an article that 
appeared a couple weeks ago in a newspaper in Pennsylvania, in 
Kittanning, Pennsylvania, Armstrong County, which is not in my 
district, but I was reading here a quote from a law the 
Armstrong County district attorney, Scott Andreassi. He said, 
``What is not happening now is monitoring things like doctor 
shopping. We need to take this program a step further and 
involve the pharmacies and virtually everyone involved with 
prescriptions every step of the way. We are going to discuss it 
in the future as to how we are going to talk to one another, 
exchange information on prescription drugs and so on.'' And it 
makes me wonder, unless there is a misunderstanding of these 
programs, I am wondering if we are getting the right 
information to the right people who can really do the right 
thing for patient care? And I would think that those are under 
the jurisdiction of HHS and CDC, that we are concerned about 
people abusing drugs, doctor shopping, illicit prescriptions, 
et cetera, and looking at these together. I would hope that 
from the comments that both of you made you are going to help 
this committee get that information and can bring it to the 
committee's attention in the future. I yield back.
    Mr. Stupak. Thank you. Ms. DeGette, do you have questions?
    Ms. DeGette. Thank you, Mr. Chairman. Dr. Clark, in your 
prepared testimony, you say, ``Our strategies in prevention and 
treatment of prescription drug abuse are both targeted 
specifically to the prescription drugs themselves and to 
programs that enable prevention, intervention, and treatment of 
addictions, which can have a significant long-term impact on 
prescription drug abuse and misuse.'' That is your conclusion. 
So my question is to you, if those are your strategies, don't 
you think it would be really helpful to have NASPER to help you 
achieve those strategies?
    Dr. Clark. Clearly, having access to the electronic matrix 
where information is shared real-time between pharmacists and 
physicians and patients, through their physicians or healthcare 
provider, we would be in a much better position to assess the 
appropriateness of a particular prescription. As a physician, I 
used to work for the VA, and we had electronic records. And so 
when a patient would come in, I could pull up those records, 
and I could see what medication the patient was on, and I could 
deal with the issues of synergism, multiple prescriptions, and 
appropriate----
    Ms. DeGette. And that is part of what NASPER does, correct?
    Dr. Clark. That is part of what NASPER does, yes.
    Ms. DeGette. So I guess your answer would be, yes, that 
would assist you in these important goals of your agency.
    Dr. Clark. Yes.
    Ms. DeGette. Dr. Paulozzi, I just have a question. I was 
interested to look at your slide that shows that these 
incidences of deaths from overuse of these drugs, both in my 
area of the country, the southwestern United States, and also 
in Appalachia, are greater, and I was wondering if you have any 
indication of why that might be. Is it a systems breakdown? Is 
it for cultural reasons? What might the reasons be?
    Dr. Paulozzi. Well, thank you for that question, 
Congresswoman DeGette. New Mexico used to have the highest drug 
poisoning mortality rates in the country for many years. And it 
was thought to be related to the black-tar heroin, some of it 
coming in from Mexico, also related to maybe the cultural 
practices of use of heroin in that community. Some of the 
neighboring States to New Mexico's rates have gone up, though, 
in the last 10 or 15 years as well, so it is not clear to what 
extent that is prescription drugs and to what extent it is 
illicit drugs. But that has really historically been the focal 
point for drug poisoning, in the Southwest.
    Ms. DeGette. And we don't really know why exactly?
    Dr. Paulozzi. No, I would have to say that there are 
speculations about illicit drugs and type of heroin use in 
cultural practices.
    Ms. DeGette. In your testimony you mentioned a variety of 
surveillance and examination activities that the CDC will 
undertake this year, such as looking at prescription histories. 
This is one of the things NASPER does. It gives doctors and 
officials access to patient histories. So wouldn't it make 
sense to use the NASPER Program for this, and especially since 
it has already been authorized?
    Dr. Paulozzi. Yes, absolutely, Congresswoman. The 
information collected by prescription drug monitoring programs 
could be very useful to people like myself or State health 
departments, public health researchers at all levels, to look 
at the prescription histories of people suffering overdoses, to 
look at the trends in distributions, in county-by-county 
distributions across the State. I think it is an invaluable 
tool.
    Ms. DeGette. And you have reported unintentional deaths 
from prescription drug abuse is now the second cause of 
accidental deaths in this country, second only to traffic 
accidents. If NASPER is implemented by HHS, how would the data 
from PDMP programs help medical researchers engaged in public 
health research, like you?
    Dr. Paulozzi. Well, the data would be very helpful, 
Congresswoman, in terms of telling us what is happening with 
distributions of drugs and trends in sales of drugs. We 
currently don't have a good source of information about that. 
Proprietary information is available, but working in the public 
sector, we can't afford to buy it. In addition, the people 
doing studies, and medical examiners, just looking at the 
deaths of individuals, could benefit from being able to see 
what their prescription history has been in terms of helping to 
determine what led to their death. So there are multiple 
applications.
    Ms. DeGette. And one thing I was just sitting here thinking 
about, like with my question to you about why are the deaths 
higher in certain regions of the country, if you had that data 
you could actually see, is the use or abuse of these 
prescription drugs greater in these areas, or is it really 
illicit drugs, a fact that you can only speculate on right now? 
Correct?
    Dr. Paulozzi. Yes, that would be an additional tool. There 
are some survey data, though, that are broken down by State, 
collected by SAMHSA, about substance abuse that may be useful 
in that regard.
    Ms. DeGette. And, Dr. Clark, you were shaking your head. 
You think this could be helpful as well, I assume?
    Dr. Clark. Yes.
    Ms. DeGette. Thank you. Thank you, Mr. Chairman.
    Mr. Stupak. Thank you. Dr. Paulozzi, if I may, Ms. DeGette 
asked you about, you mentioned New Mexico and Colorado and the 
Appalachian States, and in a map of the States you have the 
highest drug poisoning rates in the country. And again, in your 
opinion, if the prescription drug monitoring programs in those 
States had interoperable capabilities, like they would under 
NASPER, do you believe that would help decrease the drug 
poisoning in those States?
    Dr. Paulozzi. Well, Mr. Chairman, I believe that the 
prescription drug monitoring programs are promising tools for 
that purpose. They would provide a lot more information in a 
timely way, both to regulators, people in public health, and 
also to physicians in trying to manage care for patients. So 
there are a lot of reasons to believe that they would be 
effective in preventing overdoses, managing care of people with 
chronic pain better.
    Mr. Stupak. Your data that you used in your study came from 
coroners and medical examiners as to the cause of death. How do 
coroners and medical examiners determine what types of 
prescription drugs were involved in these accidental deaths?
    Dr. Paulozzi. Yes, Mr. Chairman. The coroners and medical 
examiners do complete the death certificates, which are filed, 
and then those become the source of the studies that we have 
done. They determine the cause of death by a variety of means. 
They look at the death scene investigations to see what 
prescription vials are there and whether there are syringes 
that were used to inject drugs. They also, of course, do 
toxicologic testing to look for the drugs found in the 
decedents' bodies after death. They will ask questions about 
the person's history, and they may even get the record from the 
prescription drug monitoring program, if there is one in their 
State, about the person's prescription history, to look for 
signs of abuse of drugs.
    Mr. Stupak. If we had NASPER, that would provide that 
information readily available to those coroners and others, 
would it not?
    Dr. Paulozzi. Yes.
    Mr. Stupak. About the prescription drugs?
    Dr. Paulozzi. Yes, Mr. Chairman, it would.
    Mr. Stupak. Thanks. In your testimony you mentioned that 
there is a significant correlation between State drug poisoning 
rates and State sales of prescription drugs. If you were in 
charge of creating a drug monitoring program such as NASPER, 
would you choose to house it in a health agency which has 
jurisdiction over prescription drugs or a law enforcement 
agency like DOJ, and why?
    Dr. Paulozzi. Well, that is a complicated question, and I 
am not sure I really understand fully the ramifications of 
those two different choices. I can say on the one hand that 
there is a lot of use made of prescription drug monitoring 
program data by law enforcement. On the other hand, there 
should be use of NASPER-type data by physicians. I would hope 
for a system that would be accessible to everyone who needed 
access to it, with the appropriate protections of patient 
privacy, and not have the use be dictated by the location of 
the program.
    Mr. Stupak. Thank you. Dr. Clark, in the study you gave to 
our staff last night, and SAMHSA spent 18 months massaging it, 
let me ask you this. In there, it states that there is evidence 
of a negative impact on the patient's access to pain treatment. 
Are you saying that the Harold Rogers program is negatively 
impacting patients' ability to seek proper treatment on 
legitimate pain diseases?
    Dr. Clark. No, what we are saying is, looking at controlled 
substance monitoring programs generally so that comment is not 
targeted toward the Harold Rogers Program. It is saying that 
when jurisdictions implement controlled substance monitoring 
programs, there is an unintended consequence of practitioners 
altering their clinical decision-making because of the 
existence of such programs.
    Mr. Stupak. The Rogers prescription drug monitoring program 
has been around since 2002. Congress has spent $43.5 million. 
Has anyone ever assessed the success of that program, if it has 
been successful in reducing unintentional deaths in drugs, Mr. 
Clark?
    Dr. Clark. I don't think so.
    Mr. Stupak. All right. In your testimony you say that no 
organization or agency can address the program or the problem 
alone. A coordinated response is required. Does the Rogers 
program provide this coordination of agencies?
    Dr. Clark. I think under the one-government paradigm we 
should be operating with that level of coordination. It hasn't 
happened.
    Mr. Stupak. So the Rogers program doesn't support 
coordination amongst agencies, then?
    Dr. Clark. I can't articulate the explanation for the 
Rogers program's activity in that area.
    Mr. Stupak. Well, let me ask you this. Does HHS support the 
NASPER Program?
    Dr. Clark. You have heard from Secretary Leavitt. I will 
defer to his position on this matter.
    Mr. Stupak. Has Secretary Leavitt seen this report that you 
handed to us last night?
    Dr. Clark. That report has been cleared by HHS. I can't say 
whether Secretary Leavitt himself has seen the report.
    Mr. Stupak. Mr. Whitfield, for questions.
    Mr. Whitfield. Just a couple more. Obviously on an issue as 
serious as this issue, it is important that the programs, that 
they be effective and that there be a way to measure their 
effectiveness and that there be adequate oversight. And I would 
make the argument that, when you do an earmark on an 
appropriation bill, generally there is no follow-up report to 
examine its effectiveness at all. In NASPER, there is a 
requirement that after three years of operation that HHS 
conduct a study and determine how effective the program is. So 
I think that is one big difference in these programs. The 
second difference is that, under the existing DOJ program, it 
relies on the States to determine who has access to the 
information. And, for example, Indiana and Pennsylvania will 
not allow physicians access to the information. The NASPER 
Program allows physicians access to the information, allows law 
enforcement access to the information, and sets guidelines for 
privacy protection concerns. So when you look at these 
programs, I think the more balanced program overall certainly 
is NASPER and I must say that it is frustrating that the 
President signs this bill, and still there is no funding for 
this program. And it is more important than just jurisdiction. 
It is about addressing a serious problem in the country, and 
that is really what this hearing is all about. Now, Dr. Clark, 
let me ask you one question. When you all work with OMB on your 
budgetary needs, who, what is the name of the individual at OMB 
that you work with? I mean, I know that Leavitt can call Jim 
Nussle on the phone, or he can call Rob Portman on the phone, 
but at the staff level, who works with who? Between HHS and 
their budget requests and OMB?
    Dr. Clark. As I recall, the staff person is an individual 
named Patricia Smith.
    Mr. Whitfield. Patricia Smith? And then, at the White 
House, who is the White House liaison with HHS?
    Dr. Clark. I don't have that information.
    Mr. Whitfield. Thank you very much.
    Mr. Stupak. Seeing no members with further questions, I 
would like to thank this panel for their testimony today. Dr. 
Paulozzi and Dr. Clark, thank you for being here.
    Dr. Clark. Thank you.
    Dr. Paulozzi. Thank you.
    Mr. Stupak. We will call up our second panel. We have one 
witness on our second panel, and that is Dr. Andrea Trescot, 
president of the American Society of Interventional Pain 
Physicians, and she is also the director of Pain Fellowship at 
the University of Florida. We will give you just a minute, Dr. 
Trescot, and then we are ready to go. It is the policy of this 
subcommittee to take all testimony under oath. Please be 
advised that the witness has the right, under the rules of the 
House, to be advised by counsel during their testimony. Do you 
wish to be represented by counsel, doctor?
    Dr. Trescot. No, sir, I do not.
    Mr. Stupak. The witness testifies that she does not, then 
raise your right hand and take the oath.
    [Witness sworn]
    Mr. Stupak. Thank you. Let the record reflect the witness 
has answered in the affirmative. She is now under oath. Dr. 
Trescot, if you would, please, just give an opening statement, 
and then you may submit a longer statement for inclusion in the 
record, and we look forward to questions and answers. Doctor?

   TESTIMONY OF ANDREA M. TRESCOT, M.D., PRESIDENT, AMERICAN 
   SOCIETY OF INTERVENTIONAL PAIN PHYSICIANS; DIRECTOR, PAIN 
                           FELLOWSHIP

    Dr. Trescot. Thank you. Distinguished Chairman, ranking 
member, Members of Congress, and staff, my name is Dr. Andrea 
Trescot. I am very grateful for this invitation to speak before 
you regarding a critical issue, prescription drug abuse. I am 
an interventional pain physician with nearly 20 years of 
private practice experience, and earlier this year I left 
private practice to join the University of Florida and the 
Gainesville VA as Director of the Pain Fellowship Program. I am 
currently the president, as you said, of the American Society 
of Interventional Pain Physicians, ASIPP, a professional 
society with over 4000 providers. But it is in my role as a 
physician, treating patients in agonizing pain, that I come to 
you today requesting your help.
    Opioid or narcotic use and misuse is a huge and growing 
problem in the United States. As you have heard, Americans make 
up only 4 percent of the world's population, but they consume 
nearly 80 percent of the global supply of pain medicines, 99 
percent of the global supply of hydrocodone, one of our very 
easily obtained opioids, and two-thirds of the world's illegal 
drugs. Despite billions of dollars thrown at this problem we 
have not been able to reduce the Nation's substance abuse and 
addiction.
    The number of Americans abusing controlled substance drugs 
has jumped from 6.2 to 15.2 million in the last 10 years. Among 
chronic pain sufferers who receive opioids, one in five abuse 
those medications. The number of teen users, who somehow view 
prescription medicines as being safer, has more than doubled, 
but the highest use of pain relievers, non-medically, has been 
in the 18- to 25-year group. An undercover surveillance video I 
viewed last week of a pill mill showed nearly 100 people 
standing in a doctor's waiting room, waiting to pick up their 
narcotics. I was stunned by how much it looked like a bar scene 
and then realized it was because virtually person in the 
waiting room was under the age of 30. Unfortunately, the 
elderly are also at risk because of their multiple medications 
and potential drug interactions and their multiple degenerative 
joint changes. Though this population may have significant and 
legitimate opioid needs, they are at risk for diversion of 
their medications, sold for income supplementation or stolen by 
caregivers and family members.
    Approximately 75 to 90 percent of drug abusers have 
obtained their medications legally, and most through a 
prescription. We feel, therefore, that the most effective way 
of controlling this epidemic is to control the end of the pen, 
or in other words, how the medicines are prescribed. The White 
House Office of National Drug Control Policy, focusing on 
stopping use before it starts, healing drug users, and 
disrupting the market, has spent over $10 million a year since 
its enactment in 1988, with no demonstrable curb in drug abuse 
or addiction. And yet, almost a quarter of a trillion dollars 
of the Nation's yearly healthcare bill is attributed to 
substance abuse and addiction.
    We feel strongly that NASPER is a major weapon against 
prescription drug abuse. Unfortunately, the ONDCP's budget of 
$13 million doesn't include funding for NASPER, which is 
arguably the most effective program. To fight drug abuse before 
the drug is prescribed would require about $10 million, which 
is less than 1 percent of the current budget and could provide 
as much as 30 percent reduction in prescription drug abuse. Now 
NASPER was based, as you have heard, on a successful program in 
Kentucky, KASPER, which has been effective but limited because 
Kentucky has seven border States, allowing patients to take the 
prescriptions across State lines to avoid monitoring. One of 
the most important features of NASPER was the information 
sharing across State lines, but that requires each State to 
have a monitoring program in place. In this day of unfunded 
mandates, the States have been slow to enact legislation, most 
of which was inadequately funded and not designed to share 
information.
    I live in north Florida, an hour away from the Georgia 
border. Although Florida passed a bill that was named FLASPER, 
suggesting that it was part of the NASPER Program, the eventual 
legislation was castrated into a voluntary program of 
electronic prescribing. We are convinced that, had the funding 
for NASPER been in place, the law in Florida would have 
conformed to the national recommendations, which would have 
prevented Florida patients from obtaining narcotics from 
multiple doctors, whether they were day laborers or syndicated 
radio columnists. By identifying those patients who are doctor 
shopping, physicians will be able to intervene early with 
patients who are misusing and abusing their medications, 
legitimate pain patients will receive access to care they truly 
need, and we can shut down the most obvious avenue for 
obtaining fraudulent prescriptions.
    It is clear the prescription monitoring programs are 
effective specifically when they are proactive, and we feel 
NASPER is just such a program. We at ASIPP also feel that, 
since less than 40 percent of physicians receive any kind of 
training regarding pain evaluation in medical school, the White 
House should facilitate the dissemination of pain and addiction 
information to the general medical community. I have provided 
the committee with a copy of such an education tool, published 
last year by the Florida Medical Association.
    In closing, the White House has declared a total global war 
on terrorism, with a budget of $145 billion. We are asking for 
only a tiny fraction of that to battle an insidious and just as 
deadly internal threat to the welfare of this great Nation. 
Please help us in that battle by providing funding for NASPER 
as one of the major tools we have in this critical battle. 
Thank you very much, and I look forward to answering any 
questions you might have today and in the future and perhaps 
providing additional insight to some of the questions asked 
today.
    [The prepared statement of Dr. Trescot follows:]

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    Mr. Stupak. Thank you, and I will note you had presented 
longer testimony, and some of it was a paper done by Dr. 
Laxmaiah Manchikanti.
    Dr. Trescot. Manchikanti, yes, sir. And that is available 
in your packets. That has been published and available on the 
Web as well.
    Mr. Stupak. Right, and then that will be included in the 
record. But I know with the great frustration that our 
witnesses on the previous panel from CDC and SAMHSA, officials 
did not stay to listen to your testimony. I wish they would 
have, and I would like to send them a copy of your testimony 
and a copy of the pill mill tape that you did, you shot last 
week, you said.
    Dr. Trescot. Yes, sir.
    Mr. Stupak. And so, could you send the committee a copy of 
that tape? We would really like to see it.
    Dr. Trescot. I can actually provide--CBS Evening News did 
one actually of Texas, which I was asked to comment on, on air. 
The surveillance that I described is on a case that is 
currently ongoing, and certainly as soon as that case has 
adjudicated I am sure that we would be glad to provide that. 
Unfortunately, because that case is----
    Mr. Stupak. Ongoing.
    Dr. Trescot. That organization is actually currently being 
investigated. I am not at liberty to release that information.
    Mr. Stupak. When it is, and when you can, if you would, 
please provide the committee.
    Dr. Trescot. I will do the best of my ability.
    Mr. Stupak. It is a great learning tool. Now, one of the 
things that, and having practiced medicine I am sure you are 
well aware of it, we have seen, and it seems like I always hear 
stories every week, that all they did for a senior citizen was 
change their medication when they went to the hospital, or the 
medication being received from their family physician and what 
they received in the hospital was counteractive to the illness 
or the disease they are trying to prevent. Would NASPER help 
change that or get better outcomes here? It seems like we are 
prescribing, multiple doctors prescribe multiple medications, 
which does not really help out the patient at times.
    Dr. Trescot. That is absolutely a huge problem. Many 
patients now are treated at the hospital by a hospitalist and 
now their family doctor, and there is often a delay in getting 
the information from the hospital back to the primary care 
physician, and unfortunately patients in general don't often 
recognize that the name of one medicine might be the same kind 
of medicine as another. And a good example of that would be the 
difference between Vicodin and Lortab----
    Mr. Stupak. Sure.
    Dr. Trescot. Both of which are hydrocodones, both of which 
have very different names, and I in my own practice have had 
patients who have been on both medicines and had no clue they 
were exactly the same. That obviously raises the risk of 
overdose because they are taking two doses of the same 
medicine. NASPER would allow us to be able to access that 
information from all their locations, from all the prescribers, 
and to be able to sit down with the patient and, medicine by 
medicine by medicine, be able to look at the potential drug 
interactions.
    Mr. Stupak. Well, let me ask this question. The NASPER 
Program, there are requirements for receiving grant funds that 
a State has agreements with bordering States to share 
information in order to stop the doctor shopping between the 
States, and you mentioned Florida being an hour away from 
Georgia. Do you see the effects of Georgia dumping there, or 
patients going over to Florida from Georgia and vice versa?
    Dr. Trescot. There is actually a pill mill in my own 
community, and you can drive by that office and see the huge 
number of Georgia license plates in the parking lot.
    Mr. Stupak. I think Mr. Burgess might have mentioned it. 
You have mentioned it. It seems like we are aware of where 
these pill mills are, but who would have the responsibility for 
controlling or shutting them down?
    Dr. Trescot. That is why I volunteered to be the expert 
witness in this ongoing case, but this particular pill mill has 
been in existence since April. They have a physician who had 
never written--sorry--controlled substances before who in 
September, from April until September, had written at least 
8,800 different prescriptions for opioid narcotics, out of this 
one location.
    Mr. Stupak. So in order to write prescriptions you have to 
be licensed, so you have a State licensing agency, you have a 
law enforcement issue, and you have a public health issue, 
which NASPER takes those components in consideration, but, with 
all due respect to the Rogers Program, that is more oriented 
towards law enforcement. Has that been your experience?
    Dr. Trescot. Absolutely, and the problem comes in, is that 
there is no way for me as a provider, you come into my office 
complaining of low back pain. I have no test for pain, I have 
no ways of telling by looking at you whether you are really 
hurting or not. So I have two options. One is to consider you a 
potential drug abuser and refuse you the pain medicines you 
might need. The other is to be an enabler, to allow you to be 
able to scam me, just as you have scammed other doctors in the 
community, by writing a medicine because I believe you. So it 
immediately sets up an adversarial relationship. We feel that 
NASPER, because it was written to be HIPAA compliant, requires 
a written consent from you to allow me to access that data 
bank. Now obviously if you don't give that consent, I don't 
write the pain medicine.
    Mr. Stupak. Correct.
    Dr. Trescot. So it is a quid pro quo. But in any case it 
allows me to access the data bank to be able to see that you 
have not gotten medicines from any other prescribers, to be 
able to identify if you are potentially in trouble, and 
intervene before your life is destroyed, and to then be able to 
establish a caring, open relationship with you, to be able to 
give you the treatment that you deserve.
    Mr. Stupak. Two quick questions, if I may. Do you believe 
HHS is the appropriate agency to run NASPER?
    Dr. Trescot. I absolutely do. HHS is by definition involved 
with healthcare. It allows a physician intervention at an early 
point, and since the physician, as I said, is the end of the 
pen, the physician is writing the prescription that is 
therefore getting abused. So it allows it to be done at a 
physician level. DOJ focuses on criminal activity, and I will 
be honest, for instance, in the Panhandle of Florida there have 
been some very egregious DOJ activities against physicians, to 
the point that I have physicians telling me that they feel that 
there are being attacked by, and the quote is ``jack-booted 
thugs''. That has created an amazing chilling effect, so that 
patients come to me from the panhandle telling me that they do 
not have the ability to get prescription medications in the 
panhandle, and they have to come to Gainesville.
    Mr. Stupak. Quickly, any other States have a program real 
similar to NASPER? We have heard all kinds of figures----
    Dr.  Trescot. Yes. There are four.
    Mr. Stupak. Four?
    Dr. Trescot. We have got Kentucky, Utah, Idaho, and Nevada. 
Those are the only that allow physicians to have access to that 
information. Every other one denies physicians that ability.
    Mr. Stupak. Thank you. I am well over my time, but I want 
to give you and Mr. Whitfield-- questions please? Thank you 
again.
    Mr. Whitfield. Dr. Trescot, we appreciate your being here 
very much and thank you for the great job you are doing with 
the Association, and thank you for providing us with this 
magazine. And now that we understand opiate pharmacology we can 
have a better conversation with Dr. Burgess over there. But I 
am not going to ask you any questions, and here is why. Your 
testimony is the kind of testimony that we really needed when 
we were passing this legislation, and we had great testimony, 
and your testimony reaffirms the necessity for this program. 
But unfortunately our problem right now is getting the 
appropriations for it. So thank you very much for being here 
and for your continued effort in this regard.
    Mr. Stupak. Thanks, Mr. Whitfield. I know you have been a 
champion on this legislation, along with myself and others, and 
we appreciate it, and we are going to get some money to get 
this thing going. Mr. Burgess.
    Mr. Burgess. Thank you, Mr. Chairman. Thank you, Dr. 
Trescot, for being here and sharing this information with us. 
You referenced the Texas physician. Was that the same series of 
articles that I referenced in my opening statement?
    Dr. Trescot. It is actually a different one.
    Mr. Burgess. Wow.
    Dr. Trescot. This was on the CBS Evening News, was a 
physician's assistant, actually, who would see the patients 
with no--they had sent in undercover reporters with video, and 
it is all videotaped and was presented, where he would come in, 
what medicines do you want? There was no attempt at a physical 
exam, no attempt at trying to obtain a history. The reporters 
were asked at the window if they had records. They said, no. 
They said, fine. That will be $150 or $200 or $80, whichever 
one it was at that particular time. They came into the room. 
They had a blood pressure or weight taken, and then the 
physician's assistant, describing himself as a doctor, came in 
and said, what do you need? They asked for the medicines they 
wanted. The prescription was faxed over to the pharmacy, and 
actually they got medicines that they didn't even ask for, and 
with four reporters that went in, they got over 700 tablets in 
four days of addictive substances.
    Mr. Burgess. Are you familiar with the case that I 
referenced, Dr. Maynard in south Dallas?
    Dr. Trescot. Yes, sir, and it is very similar to the ones 
that we are looking at in Florida and disgustingly similar 
unfortunately.
    Mr. Burgess. And even with all of the documentary evidence 
that they brought up, this individual was given probation, and 
I guess he lost his license. I don't really know about that, 
but it seems like it was pretty difficult to build the case and 
get--realistically, he was charged with, I think, 11 counts of 
murder and gets probation. That is kind of phenomenal.
    Dr. Trescot. And yet in the panhandle a doctor who was a 
Board-Certified pain management physician, fellowship trained, 
seeing 10 patients a day, not 100, had, I believe, two patients 
who died. He was convicted and given 20 years in prison.
    Mr. Burgess. And that is actually what I was going to ask 
you about, because that occurred, I think, before I took office 
here. As a physician you worry about how to strike that right 
balance. You obviously don't want to bring the wrath of the DOJ 
down on your neck, but at the same time you are in the 
treatment room with a patient who is suffering, and your charge 
is to serve the suffering, so it sets up a conflict that almost 
cannot be resolved.
    Dr. Trescot. Except through NASPER, and that is what we 
think is, with NASPER it allows us to be able to understand 
immediately whether or not that patient is drug seeking, 
whether or not that patient is at risk for getting into 
trouble, and whether or not it is a patient who is actually 
legitimate.
    Mr. Burgess. Now who would have access to the data in 
NASPER?
    Dr. Trescot. NASPER was written so that physicians who are 
treating the patient, the pharmacists who are dispensing the 
medications, and law enforcement, only with the equivalent of a 
search warrant, would have access to that information. And so 
it is protected information, only released to those people who 
have a reason to need it.
    Mr. Burgess. What occurs in the instance where the 
prescribing physician is the non-treating physician but 
covering for someone? I mean, that is the situation where a 
drug-seeking behavior--I mean, that would happen almost every 
weekend I was on call. Someone randomly picks your name out of 
the phone book, say, I am your partner's patient, would you 
refill whatever? Either you get tricked or you don't, but how 
do you get permission from that patient to access their 
database?
    Dr. Trescot. And that is a very good question because that 
is actually, in my practice we had the policy that, for no 
reason, under any circumstances, were medications called in 
over the weekend without the ability to review the chart, even 
though it might have been one of my partners' prescriptions. 
And when the patients came in, they actually signed a sheet 
saying that they realized that, and if they had a problem and 
needed more medicines they were required to go to the emergency 
room, putting an additional burden on our already overburdened 
emergency rooms. What we visualize is that you could do the 
blanket consent that, so those physicians who have a reason to 
have access, whether--it is an agreement. If you have somebody 
who is covering you on call, you have an agreement with them 
for the exchange of that information, and that consent would 
theoretically pass over.
    Mr. Burgess. Now, are you familiar with the Genetic 
Information Non-Discrimination Act that we just passed?
    Dr. Trescot. No, I am not. I was very intrigued when you 
said that, and I wasn't familiar with it.
    Mr. Burgess. I guess arguably someone could say that the 
vulnerability to addictive behavior is an inherited trait, ergo 
it is a genetic condition, and we did put some pretty 
significant parameters around the sharing of data. I do wonder 
if we have encroached upon the turf of NAFTA with--oh, NAFTA--
NASPER with this. On the border State issue, Texas is a border 
State with another country. What do we do in that situation? 
The trans-border migration in Texas is, of course, the stuff of 
legend on Lou Dobbs every evening. It seems to me that this 
trafficking is probably just as rampant as it is across the 
Georgia-Florida border, if not more.
    Dr. Trescot. We can't control the flow of bodies much less 
small pieces of paper that are prescriptions or bottles of 
medication. Ideally, you would end up with, I would think, a 
situation where you could have an agreement with Mexico, but 
that is outside my purview.
    Mr. Burgess. But many of these substances are not 
controlled substances in Mexico, so Texas and California, New 
Mexico, and Arizona would have a unique problem in that there 
may be the flow of contraband essentially across their borders. 
Well, like Mr. Whitfield, I appreciate so much the compilation 
of data. I think it is going to be helpful going forward. I 
actually wish we had had this when we had the GINA discussion, 
but that is an issue for another day. Mr. Chairman, I do hope 
we take on the Oxycontin issue, because I think that is 
something that this committee should look into, and I know 
there have been a lot of requests in that, and I think it is 
something we should take up. And I will yield back.
    Mr. Stupak. Thank the gentleman. Doctor, thanks. 
Unfortunately we have to run to votes right now, but thanks for 
being here. Thanks for sitting through the last panel, too. You 
did do that, and we appreciate that.
    Dr. Trescot. It was my pleasure, and thank you very much 
for the invitation.
    Mr. Stupak. Thank you, and we will keep on this. We do have 
our meeting tomorrow at 3:30 with Mr. Nussle, the Director of 
the Office of Management and Budget, and maybe we can get this 
funded in the President's request next year.
    Dr. Trescot. Well, the help of both of you has been greatly 
appreciated.
    Mr. Stupak. Thanks. That concludes our questioning. I want 
to thank our witnesses for coming today and for their 
testimony. I ask for unanimous consent that the hearing record 
will remain open for 30 days for additional questions for the 
record. Without objection, the record will remain open. I ask 
unanimous consent that the contents of our document binder be 
entered in the record. Without objection, the documents will be 
entered in the record. That concludes our hearing. With no 
objection, this meeting of the subcommittee is adjourned. Thank 
you again.
    [Whereupon, at 11:45 a.m., the subcommittee was adjourned.]
    [Material submitted for inclusion in the record follows:]

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