[Senate Hearing 110-750]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 110-750

  GENERATION RX: THE ABUSE OF PRESCRIPTION AND OVER-THE-COUNTER DRUGS

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

                                HEARING

                               before the

                    SUBCOMMITTEE ON THE CONSTITUTION

                                 of the

                       COMMITTEE ON THE JUDICIARY
                          UNITED STATES SENATE

                       ONE HUNDRED TENTH CONGRESS

                             SECOND SESSION
                               __________

                             MARCH 12, 2008

                               __________

                          Serial No. J-110-80

                               __________

         Printed for the use of the Committee on the Judiciary








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                       COMMITTEE ON THE JUDICIARY

                  PATRICK J. LEAHY, Vermont, Chairman
EDWARD M. KENNEDY, Massachusetts     ARLEN SPECTER, Pennsylvania
JOSEPH R. BIDEN, Jr., Delaware       ORRIN G. HATCH, Utah
HERB KOHL, Wisconsin                 CHARLES E. GRASSLEY, Iowa
DIANNE FEINSTEIN, California         JON KYL, Arizona
RUSSELL D. FEINGOLD, Wisconsin       JEFF SESSIONS, Alabama
CHARLES E. SCHUMER, New York         LINDSEY O. GRAHAM, South Carolina
RICHARD J. DURBIN, Illinois          JOHN CORNYN, Texas
BENJAMIN L. CARDIN, Maryland         SAM BROWNBACK, Kansas
SHELDON WHITEHOUSE, Rhode Island     TOM COBURN, Oklahoma
            Bruce A. Cohen, Chief Counsel and Staff Director
           Stephanie A. Middleton, Republican Staff Director
              Nicholas A. Rossi, Republican Chief Counsel
                                 ------                                

                    Subcommittee on the Constitution

                RUSSELL D. FEINGOLD, Wisconsin, Chairman
EDWARD M. KENNEDY, Massachusetts     SAM BROWNBACK, Kansas
DIANNE FEINSTEIN, California         ARLEN SPECTER, Pennsylvania
RICHARD J. DURBIN, Illinois          LINDSEY O. GRAHAM, South Carolina
BENJAMIN L. CARDIN, Maryland         JOHN CORNYN, Texas
                    Robert F. Schiff, Chief Counsel
                   Ajit Pai, Republican Chief Counsel









                            C O N T E N T S

                              ----------                              

                    STATEMENTS OF COMMITTEE MEMBERS

                                                                   Page

Biden, Hon. Joseph H., Jr., a U.S. Senator from the State of 
  Delaware.......................................................     1
    prepared statement...........................................    44
Feinstein, Hon. Dianne, a U.S. Senator from the State of 
  California, prepared statement.................................    74
Grassley, Hon. Charles E., a U.S. Senator from the State of Iowa.     1
    prepared statement...........................................    79
Leahy, Hon. Patrick J., a U.S. Senator from the State of Vermont, 
  prepared statement.............................................    88

                               WITNESSES

Clark, Derek, Director, Clinton Substance Abuse Council, Clinton, 
  Iowa...........................................................    21
Fetko, Misty, R.N., Patent of Carl Hennon, New Albany, Ohio......    23
Pasierb, Steve, President and CEO, Patnership for a Drug-Free 
  American, New York, New York...................................    19
Paulozzi, Len, M.D., Medical Epidemiologist, National Center for 
  Injury Prevention and Control, Centers for Disease Control and 
  Prevention, Department of Health and human Services, Atlanta, 
  Georgia........................................................     4
Volkow, Nora, M.D., Director, National Institute on Drug Abuse, 
  Department of Health and Human Services, Washington, D.C.......     2

                         QUESTIONS AND ANSWERS

Responses of Derek Clark to questions submitted by Senator Biden.    31
Responses of Misty Fetko to questions submitted by Senators 
  Grassley and Biden.............................................    34
Responses of Steve Pasierb to questions submitted by Senators 
  Biden and Grassley.............................................    37
Responses of Len Paulozzi to questions submitted by Senators 
  Grassley and Biden.............................................    41

                       SUBMISSIONS FOR THE RECORD

Clark, Derek, Director, Clinton Substance Abuse Council, Clinton, 
  Iowa, statement and attachment.................................    47
Consumer Healthcare Products Association (CHPA), Washington, 
  D.C., statement................................................    60
DeLuca, Alexander, Senior Consultant, Pain Relief Newtwork, New 
  York, New York, statement......................................    66
Fetko, Misty, R.N., Patent of Carl Hennon, New Albany, Ohio, 
  statement......................................................    76
National Association of Chain Drug Stores (NACDS), Alexandria, 
  Virginia, statement............................................    90
Parsons, Charles, Executive Director, D.A.R.E. America, Los 
  Angeles, California, statement.................................    99
Pasierb, Steve, President and CEO, Patnership for a Drug-Free 
  American, New York, New York, statement........................   104
Paulozzi, Len, M.D., Medical Epidemiologist, National Center for 
  Injury Prevention and Control, Centers for Disease Control and 
  Prevention, Department of Health and Human Services, Atlanta, 
  Georgia, statement and attachment..............................   112
Reynolds, Siobhan, Pain Relief Network, President and Founder, 
  Santa FE, New Mexico, statement................................   140
Volkow, Nora, M.D., Director, National Institute on Drug Abuse, 
  Department of Health and Human Services, Washington, D.C., 
  statement......................................................   131
Zuppardi, Melissa, President of Helping America Reduce Methadone 
  Deaths (HARMD), Branford, Connecticut, statement...............   142

 
  GENERATION RX: THE ABUSE OF PRESCRIPTION AND OVER-THE-COUNTER DRUGS

                              ----------                              


                       WEDNESDAY, MARCH 12, 2008

                                       U.S. Senate,
                           Subcommittee on Crime and Drugs,
                                Committee on the Judiciary,
                                                     Washington, DC
    The Committee met, pursuant to notice, at 2:10 p.m., in 
room SD-106, Dirksen Senate Office Building, Hon. Joseph R. 
Biden, Chairman of the Subcommittee, presiding.
    Present: Senator Grassley.

OPENING STATEMENT OF HON. JOSEPH R. BIDEN, A U.S. SENATOR FROM 
                     THE STATE OF DELAWARE

    Chairman Biden. The hearing will come to order.
    I have an opening statement. My colleague and co-chair here 
can only stay about a half an hour because he has a whole lot 
of folks he has to be meeting with shortly, so I am going to 
put my opening statement in the record in order to save some 
time.
    Just let me say, though, that I really appreciate all the 
witnesses being here today. This is the Judiciary Subcommittee 
on Crime and Drugs, and the Senate Drug Caucus. We hopefully 
are going to be able to shed some much-needed light on what 
seems to be a trend that has crept into households and 
communities across the country, and that is abuse of 
prescription drugs and some over-the-counter drugs.
    But with that, as I said, I will put my opening statement 
in the record and I will yield to my colleague, if he has any 
opening statement to make.
    [The prepared statement of Senator Biden appears as a 
submission for the record.]

STATEMENT OF HON. CHUCK GRASSLEY, A U.S. SENATOR FROM THE STATE 
                            OF IOWA

    Senator Grassley. Yes. I have got a long one, so I should 
put it in the record, too. But I would like to summarize a 
little bit. Over here on the right is one of our witnesses, 
Derek Clark, from Clinton, Iowa.
    Chairman Biden. I know Clinton. I know Clinton.
    Senator Grassley. Yes. You have been in every county in 
Iowa.
    Chairman Biden. That is true. It did not do a hell of a lot 
of good, but I was there.
    [Laughter.]
    A lot of nice people you have out there.
    Senator Grassley. Now, our witness has served as executive 
director of the Clinton Substance Abuse Council for the last 10 
years. As executive director, Mr. Clark works with a wide 
variety of community members to develop solutions to substance 
abuse problems in and around Clinton, Iowa. So, we thank you 
for being here.
    In just a way of summarizing, because it is a long 
statement I am going to put in the record, we do have some 
recent statistics of a downturn in the use of illegal drugs. 
But for the purposes of this hearing, we are finding that there 
is not this downturn, in fact, a quick awakening that needs to 
be done about the use and abuse of prescription drugs and over-
the-counter drugs.
    So to bring attention to this and to bring attention to a 
piece of legislation that you and I have put in on DXM that we 
sponsored last year, it is very important to have this hearing. 
But I think one of the most important things that can come out 
of this hearing is to alert parents who are very concerned 
about their young people's use of illegal drugs, that right 
there in the medicine cabinet could be a source of abuse and a 
major problem, and things that are harmful to health that we 
hope this hearing will bring attention to.
    Thank you.
    [The prepared statement of Senator Grassley appears as a 
submission for the record.]
    Chairman Biden. Thank you very much. As I said, we have a 
very distinguished panel, our first panel. It has not been, as 
they say, a long time between drinks before we had--Doctor, 
it's a delight to have you back. Thank you for being here. Is 
Paulozzi the correct pronunciation?
    Dr. Paulozzi. Paulozzi.
    Chairman Biden. Paulozzi. I beg your pardon. Dr. Paulozzi 
is here as well. He is a medical epidemiologist in the Division 
of Unintentional Injury Prevention at the National Center for 
Injury Prevention and in control of the CDC. He has been 
working in public health since 1983 and he's worked 8 years in 
the State health departments as an epidemiologist, focusing on 
injuries and chronic diseases. He returned to the CDC in 1993, 
and joined its Injury Center in 2000. He currently spends most 
of his time on unintentional poisoning, particularly that 
involving prescription drugs, as I understand it.
    Doctor, I am going to submit again for the record your 
background. It's impressive. Again, thank you for coming back. 
I appreciate it very, very much. It's an honor to have you 
here.
    With that, why don't I begin by yielding the floor and 
going to you, Doctor, first, if you will.

STATEMENT OF NORA VOLKOW, M.D., DIRECTOR, NATIONAL INSTITUTE ON 
   DRUG ABUSE, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, 
                         WASHINGTON, DC

    Dr. Volkow. Yes. Good afternoon. The privilege is mine to 
be here.
    In 2006, it is estimated that 7 million individuals abused 
prescription medications for non-medical use in the United 
States. Seven million. Last year, actually, the number of new 
initiates for the abuse of prescription pain relievers was 
greater than the number of new initiates for marijuana. As you 
mentioned, this is in the context of decreases in illicit 
substance abuse that has occurred in the United States over the 
past 5 years.
    What are the five prescription medications that are abused? 
There are three types: stimulant medications such as Ritalin, 
and Concerta, and Adderall that are used for the treatment of 
attention deficit disorder; pain analgesics that contain 
opiates that are used for the treatment of severe to moderate 
pain, like Oxycontin and Hydrocodone; and sedative hypnotics, 
which are medications such as benzodiazepine, Xanax, Valium, 
that are used for the treatment of sleep disorders and anxiety 
disorders.
    Why are these drugs or medications specifically abused? 
They are abused because they increase in the brain the 
concentration of a chemical, dopamine, in reward centers, and 
these are exactly the mechanisms by which drugs of abuse 
produce their rewarding effects and lead to addiction.
    There are two factors that determine whether a drug will be 
rewarding vis-a-vis just being therapeutic. One of them is the 
doses used. When it is abused, it actually requires much higher 
doses than when it is used therapeutically, and much more 
frequently. The other one is the route of administration. When 
it is abused, it is usually snorted or injected, and that is 
because this leads to faster concentrations in the brain, and 
the faster the drug gets into the brain, the greater its 
rewarding effects.
    Now, what are the medical complications? Just as for 
illicit substances, just as for them, drug addiction. Now, in 
addition to that there are a series of medical complications 
that are specific for each class of drugs. The most problematic 
vis-a-vis the morbidity and mortality relates to opiate 
analgesics, such as Oxycontin and Hydrocodone because opiates 
decrease, depress the respiratory centers in the brain and can 
therefore lead to stopped breathing and death.
    The same is true for sedative hypnotics such as 
benzodiazepines, except that the therapeutic window between the 
dose that you give for medical purposes and that that will kill 
you is not as close and dangerous as it is for opiates.
    In the case of stimulants, the risks actually involve 
seizures, they involve hyperthermia, and they involve cardiac 
arrhythmias and myocardial infarctions and stroke that can also 
kill you. These drugs can also produce changes in alertness and 
motor coordination that contribute to accidents. The risk of 
complications is significantly increased when these medications 
are consumed with other medications, with alcohol, or with 
illicit substances.
    Everyone is at risk for abusing or becoming dependent on 
prescription medications. It does not matter your gender, it 
does not matter your age, it does not matter your socioeconomic 
classes. Particularly problematic, though, are adolescents, 
because in adolescents the brain is still developing and these 
medications may actually interfere with this developmental 
process.
    A question we ask--is: why are we seeing these dramatic 
increases now? There are multiple factors, but one of the most 
important has to do with significant dramatic increases in 
prescriptions for these medications, which lead of course to 
drug availability. How big are these increases? Looking at the 
numbers, they speak for themselves: sevenfold increases in the 
number of prescriptions over the past 16 years for stimulants. 
Seven-fold. They have gone from 4.5 million to 33 million. 
Opiate analgesics, fourfold increases, from more than 40 
million to almost 180 million prescriptions per year. Think 
about it: 180 million prescriptions for opiate analgesics per 
year in the United States.
    There are other factors that are likely to contribute, as 
society is increasingly willing to accept medications for the 
treatment of almost any condition: pervasive advertisement, and 
very important, the sense that because these medications are 
prescribed by physicians, they are much safer than that of 
illicit substances, which of course is an incorrect statement.
    Now, what is it that science is doing and what is it that 
NIDA is supporting? We are aware that there are two 
trajectories, one that is initiating the abuse with a 
legitimate prescription that, in individuals that are 
vulnerable, can lead to abuse. The other one that is initiating 
as drug experimentation. Both of them can lead to drug 
addiction.
    So we are developing research that entails both an 
understanding about the genetic factors that lead to this 
vulnerability, the neurobiological consequences, how do these 
drugs affect the brain and the body, and epidemiological 
factors, the pattern of their abuse. We are also helping to 
support the development of medications that can serve as 
powerful analgesics or as stimulant medications that do not 
have abuse liability, as well as new delivery systems that 
minimize the risk of addiction and dependence.
    We are also very aware that these medications, when used 
properly, can be life-saving. The importance of educating the 
community, both the medical and the lay public, as well as 
developing standards and evaluating so that we can maximize the 
therapeutic benefits of these medications and minimize their 
abuse is critical.
    The problem of prescription drug abuse is an urgent one 
that requires urgent action. I applaud you for your interest in 
this subject, and I would be happy to answer any questions you 
may have.
    Chairman Biden. Thank you.
    Doctor?

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

    Dr. Paulozzi. Good afternoon, Chairman Biden and Senator 
Grassley. My name is Dr. Leonard Paulozzi and I'm a medical 
epidemiologist with the CDC, which is part of HHS. Thanks for 
the opportunity to appear before you on behalf of CDC to 
discuss our Agency's research and prevention activities 
addressing drug overdose deaths. Thanks also for your continued 
support of CDC as we work toward becoming the healthiest 
Nation.
    I will be talking about unintentional overdose deaths 
today. Drug suicides are not included in the data I'm going to 
show you. The information I share with you will be based 
primarily on death certificates. I have a set of slides, and I 
will walk you through them. They are numbered in the bottom 
right-hand corner.
    Slide two. This slide shows the trend in the drug overdose 
deaths, or mortality, in the United States from 1970 through 
2005. As you can see from this, there has been a steady 
increase in the drug overdose mortality rate. There were 
increases for epidemics of heroin in the mid-1970s and the 
crack cocaine problems in the late 1980s and early 1990s. 
Currently, we are in the midst of what we are calling a 
prescription drug overdose epidemic. Rates now are twice the 
rates obtained during the crack cocaine era, and four to five 
times the rates in the mid-1970s.
    Chairman Biden. And we are talking, Doctor, about overdose 
deaths?
    Dr. Paulozzi. We are talking about drug overdose deaths, 
exactly.
    Chairman Biden. And the chart shows, in the upper righthand 
corner, from 2002 to 2004, prescription drug. That is 
cumulative, right? In other words, are we talking about the 
same chart?
    Dr. Paulozzi. Yes, we are. Yes.
    Chairman Biden. OK. The prescription drugs. These aren't 
totally a consequence of prescription drugs.
    Dr. Paulozzi. No.
    Chairman Biden. This is when prescription drugs became more 
of a problem.
    Dr. Paulozzi. Right. They are accounting for the increases 
I will show you in just a moment.
    Chairman Biden. Got you. Thank you.
    Dr. Paulozzi. The rate in 2005, which is the last bar in 
the figure, translates into 22,400 deaths in the United States. 
To put this into context, there were 17,000 homicides that 
year. Drug overdose deaths are second only to motor vehicle 
crashes.
    Chairman Biden. Excuse me again, Doctor.
    Dr. Paulozzi. Sure.
    Chairman Biden. This is not prescribed. This is a 
combination. We're both asking each other the same question.
    Senator Grassley. About the 22,000 deaths.
    Chairman Biden. Twenty-two thousand deaths.
    Dr. Paulozzi. Yes.
    Chairman Biden. They are overdose deaths. But are they 
overdose deaths that include people who were prescribed the 
medicine and abused it as well as people who were not 
prescribed the ``legal'' drug, but acquired it and used it, 
correct?
    Dr. Paulozzi. Yes. Just to be clear, this is total drug 
overdose deaths, drugs of all types, whether prescribed or not.
    Chairman Biden. Got you.
    Dr. Paulozzi. And in subsequent slides, I will break it 
down for you--
    Chairman Biden. OK. Thank you.
    Dr. Paulozzi.--as to what proportions were accounted for by 
prescriptions.
    Chairman Biden. That's good.
    Dr. Paulozzi. So drug overdose deaths are second only to 
motor vehicles as a cause of unintentional injury death. 
Recently, for the 45- to 54-year-old age group in the United 
States, they became the leading cause of unintentional injury 
death, passing motor vehicle crashes for the first time in as 
long as we have been tracking these statistics.
    So how do we know that this is prescription drugs? Slide 
three. This shows you the trend in drug overdose rates from 
1999 through 2005. We have broken down the earlier figure we 
were just talking about into the three major components. The 
red line is ``Deaths Due to Narcotics'', which includes the 
narcotic painkillers, cocaine, and heroin. The yellow line is 
called ``Other, Specified and Other Drugs'', and then the white 
line is ``Sedatives and Psychotherapeutic''.
    You might think from looking at this that the increase in 
recent years has been because of narcotics, which we think of 
as cocaine and heroin. But in fact that is not the case. If you 
go to the next slide, number 4, this slide also looks at 1999 
through 2004 data. It comes from a study we published in 2006, 
where we drilled down a little bit further into this narcotics 
category and were able to break it down into three main 
constituents. Those are prescription opioids, which is the line 
in red, cocaine and heroin.
    What this slide shows, is that the increase from 1999 is 
being driven by prescription opioids, which is the prescription 
painkillers. That includes Oxycontin, Vicodin, it also includes 
methadone, which is increasingly being used as a narcotic 
painkiller. Most of the increases, only some of it is due to 
cocaine, and very little is due to heroin-related deaths.
    For the most recent year of data we broke it down even more 
finely, and this is slide five. This shows you the specific 
drugs that are involved, the first listed drug codes among the 
drug overdose deaths in the latest year we have available, 
2005. The red bars represent the prescription painkillers. They 
accounted for 38 percent of these drug overdose deaths.
    As you can see, a substantial fraction had methadone listed 
as the first listed painkiller. The white bar is 
psychotherapeutic drugs, like Valium and antidepressants. 
Together, they account for 45 percent of these drug deaths. 
Street drugs--cocaine, heroin, methamphetamines--accounted for 
39 percent. The other specified drugs are mostly prescription 
drugs as well. So you can see that we have moved from an era of 
illicit drugs to an era where prescription drugs dominate the 
picture, and they are accounting for the increases you see in 
the first figure.
    With this shift in the type of drugs, we are also seeing a 
shift in the demographics, the people who are dying. It is 
still men who primarily die of drug overdose deaths, as it 
always has been, but now it is people in their 40s and early 
50s who have the highest rates of drug overdose death in the 
United States. Rates in whites recently passed drug overdose 
rates in African Americans. It is no longer an urban 
phenomenon, which is what we tend to associate with drug 
overdose deaths.
    If you look at a map of the United States, which is the 
sixth slide, you can see that the States with the highest 
rates, shown in the darkest color, are some of our more rural 
States. West Virginia, for example, has the highest rate. The 
State of Maine has a high rate. So the problem has shifted from 
an urban to a rural focus.
    Slide seven. What's causing these deaths? These are not the 
accidental poisoning deaths of children and these are not 
elderly people mistakenly taking too much medication. These 
deaths are related to the increasing use of certain 
prescription drugs, particularly the painkillers, by people in 
the middle years of life. In most of these deaths, there is 
evidence that they were related to the misuse or abuse of 
prescription drugs.
    Slide eight shows the same trend. It marks on that a red 
line showing sales of painkillers, indicating since painkiller 
sales seem to be tracking with--we expect an increase in 2006 
in the mortality rates. Indeed, data from the Drug Abuse 
Warning Network's Emergency Department Surveillance System 
shows an increase in the number of emergency department visits 
associated with opioid painkillers in all the years since 2005 
through 2007.
    Slide nine. What can we do about this? We need to get the 
most out of State prescription drug monitoring programs to 
identify doctors and patients who are abusing the system. We 
need to modify patients' behavior with insurance mechanisms. 
Hospitals might require screening for substance abuse in their 
emergency departments before opioids are prescribed. Primary 
care doctors need practice guidelines for when to prescribe and 
when to take people off the drugs. The drug manufacturers can 
make the prescription drugs more tamper-resistant so people do 
not crush them, dissolve them, and inject them.
    Prescription overdoses are a serious public health problem, 
and the CDC will continue to respond with surveillance and 
epidemiologic studies and evaluation of interventions.
    I would like to thank you for the opportunity to talk about 
this problem, and I appreciate your continued support of the 
CDC Injury Center. I would be happy to answer any questions.
    [The prepared statement of Dr. Paulozzi appears as a 
submission for the record.]
    Chairman Biden. Thank you. You both represent two of the 
greatest assets this country has, NIH and CDC.
    I have a lot of questions, which is very convenient that I 
am the only one here, so I get to ask them.
    [Laughter.]
    My staff is going to be upset because I am not using their 
questions.
    Folks, let me ask, the NIH is looking at--Doctor, you 
indicated, looking at genetic factors. Going to be looking at, 
or have begun. I was not quite sure I understood your 
statement. Talk to me a little bit about that. Tell me what you 
are doing different at NIH recently relative to looking at 
genetic factors relating to drug abuse.
    Dr. Volkow. For many years now, at NIDA we have been 
studying the genetic factors that makes individuals more 
vulnerable to experimenting with drugs, and when they 
experiment with drugs, as we know, not everybody becomes 
addicted. So what are the genetic factors that lead to people 
becoming addicted and those that do not? We know that 
approximately 50 percent of drug vulnerability to the risk of 
addiction is genetically determined.
    What we are doing now vis-a-vis this new problem of 
addiction to prescription medications, it becomes increasingly 
urgent to try to understand what those vulnerabilities may be, 
because, for example, for me as a physician, having a patient 
that may require a strong medication against pain, it will be 
incredibly important to know their risk. Why? Because if they 
do have the genetics and vulnerability for addiction, the way 
that I will prescribe may be affected by it. Thus, from the 
medical perspective that becomes a very urgent need.
    Genetics is also important because, as you identify what 
genes are involved in vulnerability, what we are finding, for 
example, is we are uncovering genes that we have never paid 
attention to, so new molecules that can now be looked into as 
potential treatments, or even prevention strategies for 
addiction. That is why this area of research is so important.
    Chairman Biden. One of the areas that I have had the 
greatest interest in for over 30 years, is this area, all the 
way back to dealing with trying to find--I introduced years and 
years ago legislation calling for the expenditure of a billion 
dollars a year, and then I went to a billion dollar program to 
find antigens or antagonists for certain drugs.
    The drug companies do not want to become the drug company. 
Drug companies do not want to do this investigation. I 
understand why. Even if they find ``a cure'' for cocaine 
addiction, folks who are addicted ain't looking to buy it, 
don't have the money to buy it. The universe is not that big, 
they're not going to make that much on it. So we came up with 
the Orphan Drug Act a long time ago to try to promote that.
    One of the things I find startling is the number of doctors 
who do not ask before they prescribe painkillers, even whether 
or not someone is a recovering alcoholic or a recovering drug 
abuser, someone in recovery. Well, they are always in recovery. 
But let me ask you a crazy question. Do they teach that in 
medical school? I mean, I am not being a wise guy, now. I am 
being deadly earnest. I am not being a wise guy and I'm not out 
looking to pick on the medical profession, or anyone else.
    But it astounds me, the number of times--having an uncle 
who is an alcoholic, and a brother who is a recovering 
alcoholic, the number of times that, you know, they have other 
physical ailments. In other words, in one case, broken bones. 
The prescription is just automatic. No one asked any questions. 
Is that part of the protocol that more doctors are learning 
about or is that even worth the effort?
    Dr. Volkow. The answer is, of course it's worth the effort. 
I am very sensitive to that same issue, and I'm sensitive 
because I've encountered multiple cases where patients have 
relapsed, that had a problem with drug abuse, because they were 
given a pain opiate and the doctor never asked the question.
    I also smile because it has been also very frustrating for 
me to be aware that in the medical system there is very little 
education regarding substance abuse. As a result of that, 
medical students are not taught how to screen and evaluate it. 
That is a lost opportunity, because by doing an intervention at 
that point where patients go to seek help, you can have a much 
greater impact.
    With respect to opiate medications, while we do not have 
the genetics about what makes you vulnerable, we know that 
individuals that have a past history of drug abuse or 
dependence in themselves or their family members are likely to 
be at greater risk. I just add that that's not just for illicit 
substances, it is alcohol, it is nicotine. If you have a past 
history of nicotine dependence, you are very likely to have a 
higher risk of becoming dependent. Physicians are not asking.
    So we put an initiative--that was what I was mentioning, 
the issue of education, to really develop educational 
guidelines for medical students and specialties to be able to 
recognize and do interventions in the case of substance abuse.
    Chairman Biden. Doctor, do you have any response?
    Dr. Paulozzi. Yes. I think that most physicians today have 
gotten some training. But for most, it's focused on the illicit 
drugs. The widespread use of powerful narcotic painkillers is a 
relatively recent phenomenon in the United States. It is really 
just since 1990 and 1992 that these drugs have come into favor.
    Chairman Biden. Why?
    Dr. Paulozzi. Well, there was around the time a sense that 
pain is being under treated in the United States, that people 
who suffer from serious diseases like cancer were not being 
given narcotics for fear of addiction. A lot of that was 
definitely the case. There were some studies that suggested the 
risk was low for use of opioids. The drugs are safe and 
effective, when used as directed. But the key is in that phrase 
``as directed''.
    What's happened, is physicians today do not have a great 
deal of experience, and certainly not training in medical 
school, for the management of long-term opioid therapy. There 
are guidelines out there, but we don't think they're being 
routinely followed.
    Chairman Biden. What I find kind of astounding, is I can 
understand the increase because some of these drugs are 
relatively new to the market in the last decade, decade and a 
half. As you said, used as prescribed, they're of great benefit 
to people. But I didn't realize that there were, respectively, 
seven and four times--in the case of opiates, it as seven 
times. Is that correct?
    Dr. Volkow. Four times.
    Chairman Biden. Four times. In the case of stimulants?
    Dr. Volkow. Seven times.
    Chairman Biden. Seven times the number of prescriptions 
written. Now, I mean, that surely does not correspond to 
population increases. I should not say ``surely''. It doesn't 
appear to me to relate to that many new and more effective, 
efficacious stimulants and/or opiates that are prescribable 
now. So has there been any study done to suggest that?
    We're going to hear from a witness on a second panel who's 
done a lot of good work in the prevention area, and indicated 
that abuse of prescription drugs tends to be for reasons--as I 
remember reading the testimony last night on my way home on the 
train--that had to do with pressure from grades, classes, 
studying for a test, coming down after a stressful day as 
opposed to what I would have thought back in the old days when 
I was doing most of this work, was just to literally feel the 
effect, the ``abuse'' factor just because it felt good, 
dopamine was produced in the case of opiates.
    So are there any studies out there indicating why this 
incredibly exponential increase in the number of prescriptions 
written?
    Dr. Volkow. Well, certainly, epidemiologists have to look 
at this to understand why there are increases. You are pointing 
out, there are multiple factors. That's going to be dependent 
also on the age of individuals. Among college students, for 
example, there have been studies that actually determine 
exactly that, that the reason why they are abusing--and this 
relates to stimulant medications--is in order to improve their 
cognitive performance.
    Just today I got an e-mail from a professor at Stony Brook 
that said he was approached by a student because he was 
concerned that his fellow students were taking stimulants for 
study, and he resented it because they could study more, so he 
wanted my advice. So these have been documented as one of the 
reasons we see an increase in the use of stimulant medications 
in college years.
    With respect to pain medications--that is why I repeated 
it, 180 million prescriptions per year in the United States. 
How many individuals do we have in the United States? There are 
3 million people that suffer from severe pain, and still it's 
180 million. I think it reflects a greater propensity to give 
opiate medications by the medical community.
    Again, I do respect the tremendous value of opiate 
medications, but I do believe at the same time, while we are 
under-medicating patients that need it, we are also over-
medicating individuals that we should not. For many years, we 
still believed in the medical community that if you have pain 
and you get an opiate medication, you are not going to become 
addicted, that pain protects you. The epidemiological data show 
that that's not the case. Approximately 5 to 7 percent of those 
individuals will become dependent. So there is, again, the lack 
of proper understanding about the effects of these medications 
that has led, I think, to increasing the risk of seeing these 
diversions of painkillers.
    Chairman Biden. I am going to repeat something you said, 
because I hear it all the time in the community. Not all the 
time. I hear it in the community. Consuming an opiate to deal 
with pain, if you're really in pain, you are not going to 
become addicted. The pain somehow is the thing that keeps you 
from being addicted to the very thing you're taking in order to 
reduce the pain. That is not physiologically correct, is it?
    Dr. Volkow. Well, what the epidemiological data are 
showing, is it is not. It's protective. It's definitely not a 
complete protection, because we are seeing people that have 
pain are becoming dependent through their opiate medication. 
Now we're actually studying in animal models the extent to 
which we can prevent the dependence, or in certain instances 
accelerate the dependence, by pain. So it depends how severe 
the pain is, how you properly are scheduling the doses. So 
certainly the answer to, is pain protective so you don't have 
to worry, the answer is no. Even with pain, you can become 
dependent to opiates.
    Chairman Biden. Now, methadone. We've gone through cycles 
over the last 75 years dealing with how we view methadone. Back 
in the late 1980s and early 1990s there was sort of a 
renaissance of the notion that in order to treat heroin--or not 
treat it, but as a substitute, basically--became, once again, 
viewed as a more appropriate avenue. Methadone clinics were 
kind of shut down, then they were opened up and increased.
    What is the reason for the methadone? Are there more 
methadone clinics? Are these people who are, in your chart, 
overdosing, including the 16 or whatever percent of those who 
OD'd were because of methadone, are they people who are in 
methadone clinics who are trying to beat heroin and then 
abusing the methadone, or is this a prescription written for 
other reasons than dealing with heroin addiction?
    Dr. Paulozzi. Well, I am glad you asked the question, 
because we do think this is methadone written for pain rather 
than methadone dispensed by narcotics treatment programs.
    Chairman Biden. Right.
    Dr. Paulozzi. This is methadone in pill form. The clinics 
use methadone in liquid and wafer form. Various reasons tell us 
that this is probably a painkiller problem. Studies that have 
looked at the data from medical examiners have found that only 
a small fraction of the people dying with methadone in their 
system were ever enrolled in methadone treatment programs in 
their States.
    Chairman Biden. That's an important thing to know, because 
urban legend spreads pretty rapidly. So if you give me that 
last statistic, of the people--
    Dr. Paulozzi. Of the people who die and go to the medical 
examiner and they find methadone in their bodies--
    Chairman Biden. Right.
    Dr. Paulozzi.--a small percentage--some studies, fewer than 
10 percent--have ever been enrolled in a narcotics treatment 
program.
    Chairman Biden. Got you. OK.
    Now, the other statistic--and every cycle I get back into 
it. There is always something that surprises me. What surprises 
me, and I'm going to be revealing my ignorance here, is the age 
of those abusing prescription drugs. I would bet you that the 
vast majority of my colleagues, and maybe the public if they 
were aware this hearing was being held, would assume--we're 
going to hear witnesses on this issue--that we're talking about 
teenagers, and sometimes pre-teens and teenagers, students for 
whom, as you pointed out, there's more--it's only exceeded by 
marijuana in the last year, 2007. Is that right?
    Dr. Volkow. 2006.
    Chairman Biden. 2006. As sort of the gateway drug, the 
first time using or abusing a substance. It is, first marijuana 
is Number one, and prescription drugs are number two. Is that 
correct?
    Dr. Volkow. Well, last year, prescriptions outdid 
marijuana.
    Chairman Biden. OK.
    Dr. Volkow. prescription pain relievers outdid marijuana.
    Chairman Biden. All right. Thank you.
    Now, again, when we use those kinds of statistics, which 
are accurate, it leads people to again focus on young people. 
But one of you gave a statistic that is either the bulk of the 
overdose deaths, that people between the ages of 25 and 40, is 
that what you said?
    Dr. Paulozzi. Well, no. I think I said that the highest 
drug overdose mortality rates are with people are in their 40s.
    Chairman Biden. Yes.
    Dr. Paulozzi. The rates basically rise up to 45 and then 
come back down again. It is really the baby boomer generation 
in their 40s and early 50s that have the highest death rates. 
That doesn't necessarily mean that the abuse rates follow that 
same pattern.
    Chairman Biden. That's what I wanted to clarify.
    Dr. Paulozzi. Yes. For some reason, the deaths are more 
concentrated in the middle age group. Maybe they use different 
drugs, maybe they inject them more, maybe they use heavier 
doses. But I think surveys from SAMHSA have indicated that 
people in their 20s may be more likely to report having used a 
drug recreationally in the previous month.
    Chairman Biden. Got you.
    Now, the other issue was, we talked about at the last 
hearing we had, Doctor, was the means of ingesting this to 
abuse it. It's not just merely the abuse, it's the manner in 
which you abuse. So snorting or injecting an opiate, a 
prescription drug that's an opiate is, in fact, a quicker way 
to get a bigger bang out of whatever you're seeking.
    Now, both of you said that that there are--are there any 
discussions, are there any actions being taken on making these 
drugs more tamper-resistant? What are some of those methods? 
Are there any manufacturers who are spending any time on this, 
as you know?
    Dr. Volkow. Multiple pharmaceutical companies are spending 
time on this. This is a key component. For many, many years, 
pharmaceutical companies have been working on developing both 
analgesics that do not produce independence. Working with 
changing the delivery system has already happened. Many 
medications, for example, in terms of stimulants, are already 
delivered through mechanisms that lead to slower uptake into 
the brain, for example, Concerta, with longer-lasting effects. 
Oxycontin actually started as a medication that, in principle, 
should lead to slower, more stable, uptake in the brain.
    The problem with it is, you can extract the substance and 
then inject it. So what the companies are now working with, are 
new polymers where you can actually mix the drug with them, and 
even if you crush it, you cannot inject it. So that's the issue 
of tampering.
    Chairman Biden. Good.
    Dr. Volkow. The other approach that, for example, we've 
been working with for the development of medications against 
heroin and for the treatment of addiction to pain analgesics, 
is to mix these medications with an antagonist. When you take 
it orally, the antagonist will not be absorbed. But when you 
take the same medication and inject it, the antagonist will 
interfere with its effects. So, these are two mechanisms.
    Chairman Biden. Is that occurring now? I mean, are 
pharmaceutical companies doing that now?
    Dr. Volkow. Correct. Absolutely. Absolutely. It's a major 
area of research, both on opiate medications and stimulants.
    Chairman Biden. Got you.
    Now, one of the statistics that gets people's attention, 
because when we use percentages, which we have a tendency to 
do, there's been an X percent increase, so on, and so forth. It 
doesn't calculate. But I found the comparison that you used, 
Doctor, saying that those dying from overdose of prescribed and 
controlled substances exceeded the number of, or was second 
only to, last year, motor vehicle deaths and this year exceeded 
motor vehicle deaths?
    Dr. Paulozzi. No, no. I'm sorry. What I said was that 
unintentional drug poisonings are second to motor vehicle 
deaths. They are still second to motor vehicle crashes.
    Chairman Biden. There are roughly 22?
    Dr. Paulozzi. There are roughly 22,400. Motor vehicles are 
roughly 43,000 per year. I made the comparison to homicide, 
which has 17,000 deaths per year. I mentioned that in the 45 to 
54 age group. Just in that age group, there are now more 
overdose deaths than there are motor vehicle crashes.
    Chairman Biden. OK. That's what you said. It was only in 
that age group.
    Dr. Paulozzi. In that age group.
    Chairman Biden. OK.
    Going back to what I was sort of stumbling around trying to 
get at, is is there an explanation of why younger people using 
these drugs have a lower mortality rate from overdose than 
older people? Not older, but people in their 40s, for example.
    Dr. Paulozzi. Well, it's conjecture, really. It may have 
something to do with the differences in the types of drugs they 
use. They may be less likely to tamper with the drugs and 
inject them. It may have something to do with the pattern and 
chronicity of their use. It could be that people dying in their 
40s are people who are long-term drug users who use much larger 
amounts of drugs.
    Chairman Biden. OK.
    And is it true--and I'd ask either one of you, if you 
know--that there is the perception--are there any data that 
demonstrate this? The perception, particularly among young 
people, that the abuse of a prescription drug is less dangerous 
than the abuse of a controlled substance, Schedule I or II 
substance?
    Dr. Volkow. Yes, indeed. There have been epidemiological 
papers that actually have documented specifically what you are 
saying, that indeed, young people overall have a sense that 
these are safer drugs, because after all they are being 
prescribed by physicians.
    Dr. Paulozzi. And the potency has been established. It's 
not like they're dealing with an unknown, in a sense.
    Chairman Biden. Yes.
    Dr. Paulozzi. There's no risk of HIV from these drugs. It's 
because most of the exposure is oral with the prescription 
opioids. It may be a variety of reasons.
    Chairman Biden. Now, the recent monitoring figures in the 
survey, the Monitoring the Future Survey, showed that 7 of the 
top 11 drugs most commonly abused by high school seniors are 
prescription drugs or over-the-counter drugs, not illegal 
street drugs. Now, this figure strikes me as being different 
than it was a couple of decades ago. Have trends always shown 
that medicine abuse is such a large proportion of the problem 
among teenagers? Did we just start asking that question or is 
this a genuinely new phenomenon?
    Dr. Volkow. Well, we have been asking the question in 
Monitoring the Future about certain prescription medications 
now for many years. Dextromethorphan is a new addition, because 
we started to see increasing numbers of emergency room 
admissions mentioning dextromethorphan. So based on data from 
both the National Survey on Drug Use and Health and the 
Monitoring the Future Survey, there were indications of 
increased prescription medication abuse, particularly opiates, 
among youth and young adults beginning in the mid-1990s.
    Some of the medications are new. In the past, for example, 
Monitoring the Future did not differentiate among the opiate 
medications like Hydrocodone or Oxycontin. However, since 2002, 
we have asked about these medications separately and have seen 
steady but alarmingly high levels of abuse among high school 
seniors: about 5% abusing Oxycontin and about 10% abusing 
Vicodin in the past year. Among the stimulant medications, we 
now also differentiate methylphenidate. For the past few years, 
abuse of stimulants and tranquilizers has been more or less 
stable. However, we did see the increases in the abuse of 
sedatives up until this past year, which was the first to show 
a decline.
    The sustained high levels of Vicodin and Oxycontin abuse 
among adolescents took us by surprise because we did not have a 
sense about how use of opiates affects adolescents, because 
most of the heroin abusers were in their 20s. So all of us in 
the medical community were faced with very young people abusing 
opiate medications, with which we had no experience.
    Chairman Biden. I see. There does seem, just from a 
layperson's eyes, a correlation between the number of 
prescriptions written and the increase in these studies. I 
mean, if you have a seven-times increase in opiate 
prescriptions that are written since the mid-1990s to today and 
you see this kind of increase, there is some correlation, I 
guess. I mean, is it that they're just more available in your 
parents' medicine cabinet?
    Dr. Volkow. It's both. There are two factors that determine 
the extent to which you will have abuse of a substance. Number 
one, availability, so by increasing this massive number of 
prescriptions. It's fourfold in opiates, sevenfold in 
stimulants. So you increase prescriptions, you increase 
production. So in parallel, there is an increase in production, 
so there's more drug available.
    The second one, which is very important--almost as 
important--is the sense that you have another using the drug. 
So if you believe that others are using, whether it's true or 
not, they're much more likely to actually experiment with that 
drug and use it than you have the sense that it's not. So in 
stimulant medications, they are so widely prescribed among 
teenagers or children, that kids feel that it's actually a safe 
thing to do.
    They get it from their friends, actually very frequently. 
So both of those two are contributing. The excess availability, 
the fact that there's much more medication available, and the 
other one, the perception that people are taking it and nothing 
bad is happening to them.
    Chairman Biden. Now, the last question I have is, tell me 
if there is a correlation between the abuse of stimulants, for 
example, and moving on to controlled substances. In other 
words, one of the things I remember is that you find real 
serious drug abusers deciding they need just a higher and 
higher high, so they keep figuring out ways to concoct what 
they're ingesting in order to get a bigger hit from what 
they're doing.
    Is that part of the pattern? A kid abuses a drug that his 
friend is taking for attention deficit syndrome that has been 
prescribed by his doctor. Does that kid end up staying in that 
realm, or is there a likelihood that they move into other 
drugs, street drugs? I mean, is there any correlation between 
prescription drug abuse and what people refer to as street 
drugs?
    Dr. Volkow. We know that, for the opiate analgesics, there 
is clear-cut evidence that initiation with an opiate analgesic, 
in many instances, can precede the initiation of heroin. The 
individual becomes dependent to it and then they shift to 
heroin, which is less expensive.
    In the case of stimulant medications, a kid abusing it, not 
using it for prescription reasons, passing to other drugs, 
illicit drugs, there, I do not know that we have sufficient 
data yet to actually determine that answer.
    Chairman Biden. Do you have any view on that, Doctor?
    Dr. Paulozzi. I would agree. I don't think we have the 
data.
    Chairman Biden. Now, what's the difference in the treatment 
regime, if there is any, for addiction to pain relief medicine 
like Vicodin compared to illegal drugs like heroin?
    Dr. Volkow. Well, there is a significant difference. 
Usually what happens, it is usually reflected in two aspects of 
them. A heroin abuser usually has histories, much longer 
histories, of abuse and, per potency of the drug, has been 
exposed for many more years to a much more potent drug. They 
usually have initiated the abuse of the substance much younger 
than for prescription medications.
    As a result of that, that increases their risk and they 
need much higher doses, for example, of methadone to be able to 
control withdrawal. When you have someone that is initiated in 
opiate analgesics, they tend to have shorter periods of time. 
Many of them may have been taking drugs that are much less 
potent, like Hydrocodone, so you can manage them with much 
lower doses of methadone, or even better with buperenorphine. 
In general, their outcomes are much better.
    The issue that is problematic, is if you have a patient 
that has genuine pain that requires an opiate medication and it 
is at the same time addictive, that is the challenge because 
you need to treat the pain, while at the same time monitoring 
that addictive component of that individual. That's where the 
issue becomes much harder to deal with.
    If chronic pain is not an issue, then your outcomes are 
much, much better with someone that is addicted to opiate 
analgesics for these demographic characteristics.
    Chairman Biden. I am trying to see. I do not want to keep 
you too long here.
    Is there a different profile--and you may not know this. I 
mean, there may not be any studies done on this--of the kid 
whose introduction to abuse is through prescription drugs and 
the profile of a kid whose introduction of drugs is through the 
street with cocaine or methamphetamine or speed? Are there 
different characteristics or are they not able to be 
differentiated?
    Dr. Volkow. Well, there is not sufficient data to tell you 
categorically, but I can tell you what data has emerged from 
it. The differences tend to actually relate more to 
environmental factors than anything else. So if you come from, 
for example, a rural area where methamphetamine--like in 
Hawaii--is widely available, the likelihood that you actually 
may even initiate with methamphetamine is much higher than if 
you come from New York, where it has actually been shown by 
these geographical areas, also the likelihood of initiating 
prescription medication is much lower. But on the other hand, 
if you are in New York in a neighborhood where there is a lot 
of cocaine, you may initiate that way, or marijuana.
    Again, people don't necessarily consider it, and yet it is 
very important, that in most instances the first drug of 
abuse--in most instances--is either nicotine or alcohol, and 
from there you can go into marijuana or you can go into 
prescription medications. Which one you choose may be more of a 
function of access to that medication than itself the 
properties of the drug or the unique characteristic of the 
person.
    Now, having said that, there's another thing that we need 
to consider that we also recognize. I told you, people who are 
in pain are basically prescribed medications, but the other 
side is people that may have an underlying psychiatric disorder 
that is not recognized and are at greater risk of ending up 
using these medications as a mechanism of medicating 
themselves.
    So kids that may have depression, that may have attention 
deficit disorder may be at higher risk because they do not feel 
comfortable. They take a drug by experimenting and they feel 
better, and then they learn that, and without really being 
conscious about it they start to take it because they improve, 
temporarily, their performance. Long term, it actually makes it 
worse, but short term, they may feel better. So that is the 
other aspect, that a kid having a psychiatric disorder that is 
not properly diagnosed may be at greater risk of abusing 
stimulants because he actually may feel better with them.
    Chairman Biden. Not directly related, there is a recent 
piece I read about the number of Americans who have been 
diagnosed with depression. The essence of the article was, it's 
a staggering larger number. If I can make an analogy. When I 
started doing a lot of research about violence against women 
and statistics started coming out from the FBI crime statistics 
between the late 1970s and early 1980s, it rose precipitously, 
the statistics-reported crimes.
    After literally over a thousand hours of hearings we had 
over that whole period, it turned out that some portion of it 
was the feeling of women being more liberated to report. It 
sounds like an oxymoron, liberated to report abuse. But who 
were more inclined to report abuse than their mothers would 
have reported that abuse, or their counterparts 15 years 
earlier would have.
    Is it that people are a hell of a lot more depressed in 
America or is that it is sort of the diagnosis of choice these 
days when people used to deal with problems better? Talk to me 
about that a little bit, about depression and the correlation.
    Dr. Volkow. Yes. You are picking up on something else that 
alerted us in the psychiatric community. Now I'm speaking as a 
psychiatrist, because there is a National Institute of Mental 
Health on this issue. There's been significant increases in the 
diagnosis of depression, and also particularly in young 
children. The numbers are really staggering and it doesn't seem 
to be abating.
    Is it because we really are seeing an increase in 
depression or is it because we are recognizing it more, as you 
say? It's likely that both cases would be the case. It's 
evident that more symptomatic cases are being diagnosed that in 
the past would not have met criteria for diagnosis and 
treatment, and that's where that same issue happens for the 
case of personality disorders--not just depression, but 
personality disorders or autistic type syndrome disorders, not 
autism.
    So it is possible that we are diagnosing many more and 
we're diagnosing people that, per se, don't meet the criteria 
of depression itself. However, when you see numbers like that, 
it's your responsibility to try to understand if indeed there 
is an increase of the disease itself.
    Based on the data, I do not think that we can say that 
there is such an increase, however, we cannot rule it out. It's 
not just for depression. If you look at the statistics in 
psychiatry, there's a significant increase in cases of 
attention deficit/hyperactivity disorder; obviously the case of 
autism has attracted a lot of attention.
    Chairman Biden. Well, thank you very much. As you can tell, 
I could keep asking you questions all day because this 
fascinates me, and I think it's a big, big deal. But I've 
trespassed on your time too much already. Do either of you have 
any closing comment you'd like to make to the committee as to 
what you think we should be doing most?
    Dr. Paulozzi. Well, I appreciate the opportunity to speak 
here. I think a lot more work needs to be done to investigate 
the risk factors for these deaths, to look into the wide 
variation geographically across the country, both in the 
overdose death rates and in the rates of prescribing from one 
State to another as to the reasons for that. We'll continue to 
do our work in surveillance and etiologic studies and try to 
evaluate the impact of some interventions at CDC.
    Dr. Volkow. My perspective is, my ending remark is that 
this is an urgent problem that needs urgent action. It was very 
categorical, the way that I feel. We're already seeing 
significant increases in mortality associated from prescription 
medication. I think that slide number two that Dr. Paulozzi 
showed speaks for itself.
    The other thing is, we are seeing an increasing number of 
people requesting treatment for drug dependence, both for 
opiate analgesics and stimulants. They are just going way, way 
up. At the same time, we are increasing the number of people 
being prescribed these medications. We need to be aware of what 
has happened in the past. We had an epidemic of stimulant abuse 
in the United States in the 1960s which was very much tied to 
the increasing prescriptions at that time for medications to 
lose weight.
    We need to learn from those past experiences, because if we 
do not control these we will have a serious problem of 
dependence, not just in terms of abuse and addiction, not just 
in opiates, but also for stimulant medications. This, it has 
been shown, can have very adverse consequences. So I applaud 
you for your leadership, because this is an area that in my 
view has not received the level of attention that it deserves.
    Chairman Biden. Quite frankly, the reason it got my 
attention, is it seems to me that I've been doing this long 
enough to notice and to observe that there are sort of early 
warning signs that a new epidemic is on its way. I remember, 
years ago, writing a report saying Ice is on its way, that 
methamphetamine is going to be a giant problem, and no one 
wanted to pay attention. It was coming out of Hawaii at the 
time. It was like, OK, well, we've got an isolated problem. I 
don't mean that like I was some kind of oracle. I don't mean 
that. A lot of experts like you had come before my committee 
and talked about it.
    One of the things that I am least informed about is what is 
reasonable to expect of the medical profession, because again 
they are overburdened in a whole lot of ways. I mean, what is 
reasonable to expect of the medical profession in terms of the 
regimes for prescribing, essentially the sieve they should put 
their patients through before they decide to prescribe, and 
what to prescribe. I mean, it's a pretty extensive problem.
    So for me, one of the things we're going to be pursuing, I 
will pursue privately as well with the medical profession, the 
AMA, and others, is what do they think about this? I mean, what 
are they thinking about? What are they recommending? What are 
the medical schools talking about? What are young doctors being 
trained to do? How high up on the agenda is this?
    The whole issue of drug abuse has so many complicated 
ramifications for society, economically, politically, 
criminally, and physically. I mean, I've always thought--and 
I'm no expert on this--that the medical profession has almost, 
in a sense, understandably basically said this is not on my 
watch, this is not really our responsibility, it's the 
policymakers'. But it seems to me, we need to look to them for 
some guidance.
    Well, I thank you both very, very much for being here. I do 
appreciate your time. As I warned the Doctor last time around, 
we'll call on you again. We're like poor relatives. When you 
say you'll show up, we invite you. So, I appreciate the help 
very, very much. Thank you.
    Dr. Volkow. Thanks to you.
    Dr. Paulozzi. Thank you.
    Chairman Biden. Thank you, Doctors.
    Our second panel is Steven J. Pasierb, from The Partnership 
for a Drug-Free America. It's a nonprofit organization, uniting 
communications professionals, renowned scientists, and parents. 
Steve joined The Partnership in 1993 and became president in 
2001.
    Derek Clark has been the executive director for the Clinton 
Substance Abuse Council in Clinton, Iowa, a town I've learned 
to love.
    Misty Fetko--I hope I'm pronouncing correctly--is a 
registered nurse and the parent of Carl Hennon, who died 
tragically in 2002 due to an overdose of a combination of over-
the-counter and prescription pain relievers. Since then, she's 
dedicated much of her life to raising awareness about the risks 
associated with medicine abuse.
    I say to you, Ms. Fetko, I admire you doing this. As 
someone who lost a child in a different circumstance, I never 
had the nerve to face up to it. I just didn't want to deal with 
it. The fact that you are, in a sense, it's a bitter irony. 
Every time you testify, you're brought back and that takes a 
lot of courage. I want to personally thank you for being 
willing to do it.
    Why don't you, if you would, deliver your opening 
statements in the order in which you were called, and then I'll 
have some questions. Thank you.

STATEMENT OF STEVE PASIERB, PRESIDENT AND CEO, THE PARTNERSHIP 
          FOR A DRUG-FREE AMERICA, NEW YORK, NEW YORK

    Mr. Pasierb. Thank you very much, Chairman Biden. And thank 
you for calling this hearing. As you've said throughout this, 
you've been on this issue for a long time. Those of us in this 
field appreciate everything you've done, most recently with the 
dextromethorphan legislation. We were proud to support that.
    I'm going to submit to you, obviously it's been established 
here today that the abuse of prescription and over-the-counter 
medications, legal substances, of benefit if used 
appropriately, is the single most troubling phenomenon on 
today's drug abuse landscape. The Partnership has devoted a 
good measure of our research over the last 4 years, our focus, 
and our voice to this issue, yet clearly much more has to be 
done.
    The 2007 Partnership Attitude Tracking Study looked at over 
6,500 teenagers in grades 7 through 12. And what that showed, 
is we have 19 percent, or 1 in 5 teens, who are actually 
reporting that they've tried a prescription drug without having 
a prescription, so they've engaged in this behavior. One in 10 
report that they've used over-the-counter cough medicine to get 
high. As we've established, only alcohol, cigarettes, and 
marijuana are abused by teenagers at higher rates than 
prescription drugs, while cocaine, Ecstacy, and methamphetamine 
are each roughly half as prevalent as prescription drug abuse 
in these young people's lives.
    Now while it is true that the prevalence of medicine abuse 
has not increased in the last 3 years, it is troubling to 
realize that teen use of virtually all other substances of 
abuse--alcohol, tobacco, marijuana, even methamphetamine--has 
declined over that same period of time, and in fact many of 
these have been in decline steadily over the last decade.
    What has this trend really shown us about what we need to 
do as a Nation? We think there are a few areas we need to focus 
and we need to pay attention to. First, these substances are 
readily available to our teenagers across this country. They're 
getting it in their home medicine cabinets and the medicine 
cabinets of friends for free. Our data is very much in line 
with the national findings from the survey on drug use and 
health, which shows over 75 percent of teenaged prescription 
drug abusers say they got those drugs from immediate friends or 
family.
    Second, teens' perception of the risks of abuse is very 
low. Our past research shows that less than half of teens see 
great risk in experimenting with prescription pain relievers 
such as Vicodin and Oxycontin. Even more alarming on top of 
that, over one-quarter of the teens believe prescription pain 
relievers are not addictive.
    University of Michigan's Monitoring the Future survey, 
going back over 30 years, has helped us establish that we need 
that perception of risk associated with any substance of abuse. 
When they're there and social disapproval is there, those 
correlate significantly with actual teen substance abuse rates.
    So, low perception of risk, low disapproval, coupled with 
the easy availability that we've been talking about, is a 
recipe for ongoing problems.
    Research conducted by The Partnership in 2007, with support 
from Abbott Pharmaceuticals, gave us really a new light. It 
cast a light on the motivations of teens around prescription 
drug abuse. Traditionally, as you said earlier, we think about 
this as ``to party, to escape, to get a buzz, get high'', but 
our 2007 research with Abbott, like the research done among 
college students by Carol Boyd and Sean McCabe, suggests a much 
wider range of motivations for young people's abuse of 
prescription drugs beyond getting high, including an emerging 
set of what we call ``life management'' or ``regulation'' 
objectives.
    Teens appear to be abusing these drugs in a very 
utilitarian way, using stimulants to help them cram for a test 
or lose weight, pain relievers to escape some of the pressure 
they feel to perform academically or to perform socially, and 
tranquilizers to wind down at the end of a stressful day.
    Once these substances have integrated themselves into 
teens' regular lives and really have been abused as study 
aides, as management of life, as relaxation, it's going to 
become increasingly more difficult to persuade teenagers that 
these very same drugs are unnecessary and unsafe when they're 
taken without a prescription.
    Fourth, are parents, who typically are our biggest ally on 
these issues when we deal with them. They're always right at 
our side. What we find in the research, is parents are 
generally ill-equipped to deal with teens' abuse of 
prescription drugs. Parents find it hard to understand the 
scale and the purposefulness of which today's teens are abusing 
medications, because this is not something that went on when 
they themselves were teenagers. It is not clear to them that 
they may be one of the prime sources of supply to their 
teenagers out of their very own medicine cabinet.
    Further, many parents themselves--we saw this in the Abbott 
study--are engaging in a similar behavior. In our study with 
Abbott, 28 percent of parents said they had used a prescription 
drug without having a prescription for it, and 8 percent of 
parents said they had given their teenaged child a prescription 
drug that was not prescribed for that teen.
    In our studies, parents tend to underestimate the damage 
and danger of abusing medicines, some actually expressing 
relief and saw less social stigma to hear that kids might be 
abusing ``safe prescription drugs'' versus ``dangerous illegal 
street drugs.''
    Finally, the reason I don't think we're seeing declines in 
this behavior in the face of all the other declines, is simply 
our efforts as a United States up to now have not been enough. 
There simply hasn't been enough public attention, there hasn't 
been enough resources devoted to this issue like there has been 
in recent years on other emerging drug threats. Luckily, that's 
now beginning to turn.
    ONDCP's National Youth Anti-Drug Media Campaign should be 
applauded. They just invested $14 million, which will then be 
doubled by their media match to target parents around the 
prescription drug abuse issue, provide them with information on 
how to safeguard their homes, and how to keep their kids away 
from it.
    In some quarters of the pharmaceutical and over-the-counter 
drug industries, there's been real concern, there's been 
action, and there's been active support for prevention and 
education efforts, from associations like PHRMA, the 
Pharmaceutical Research and Manufacturers, from the Consumer 
Health Care Products Association, as well as select companies 
that have really stepped forward and should be commended for 
taking what is largely a proactive approach.
    As you heard, our Federal agencies, with NIDA at the lead 
and the fore, have done a superb job and have been at the 
forefront of helping us understand this problem. But reducing 
the actual abuse of these products, getting ahead of this and 
getting it turned in the right direction is going to take a 
heck of a lot more across all of our society.
    We had the tragic death of Heath Ledger, and that really 
cast a sudden spotlight on this, much like Len Bias's death did 
in 1987, which helped America understand cocaine was not a drug 
without harm and without destruction. We've got to build on 
this small bit of understanding we have right now and 
accelerate that, and devote all the necessary resources, 
education, prevention, addiction treatment that it is going to 
take to drive down the intentional abuse of these products.
    So, sir, I thank you for calling this hearing. Mr. 
Grassley, for all he does on a day in, day out basis, and we 
will stay with you on this throughout.
    Chairman Biden. Thank you.
    Mr. Clark.
    [The prepared statement of Mr. Pasierb appears as a 
submission for the record.]

  STATEMENT OF DEREK CLARK, DIRECTOR, CLINTON SUBSTANCE ABUSE 
                     COUNCIL, CLINTON, IOWA

    Mr. Clark. Chairman Biden, thank you for giving me the 
opportunity to testify.
    Chairman Biden. One important question, first. How much 
snow is on the ground?
    Mr. Clark. It's getting better.
    Chairman Biden. OK. Good.
    Mr. Clark. It's all melting right now. It's a big mess.
    Well, thank you for letting me testify on behalf of the 
Clinton Substance Abuse Council. I'm going to represent the 
community and the coalition aspect for this issue.
    First, last week a Clinton woman--let's call her Jane--was 
charged with six counts, felony counts, of fraudulently 
obtaining prescription drugs. Jane was being treated by several 
doctors over the past 3 years. She was receiving prescriptions 
for Hydrocodone and fentanyl--these are powerful drugs--from 
one doctor, while receiving methadone prescriptions from 
another doctor, and neither doctor knew this woman was seeing 
the other doctor.
    One of the fastest-growing threats to youth today is the 
abuse of prescription and over-the-counter drugs. This is true 
at the national level, as well as the local level. As a result 
of the needs assessment that we conduct for our drug-free 
communities as a grantee, we know that 15 percent of the 
Clinton Community School District 11th graders report having 
used prescription drug medication not prescribed to them at 
least once in the last 30 days. That's compared to 7 percent of 
all Iowa 11th grade students.
    Eleven percent of Clinton Community School District 11th 
grade students report having used over-the-counter medications 
different from the directions at least once in the past 30 
days, and this is compared to 7 percent of Iowa 11th grade 
students.
    While prescription over-the-counter drug abuse is clearly a 
problem, because the Clinton Substance Abuse Council is a Drug-
Free Communities grantee, we have the necessary infrastructure 
in place to effectively deal with this issue and involve all 
sectors of the community. This includes law enforcement, 
schools, parents, youth, and the business and faith 
communities.
    The Clinton Substance Abuse Council uses the strategic 
prevention framework when conducting their community planning 
and decisionmaking process. This is a five-step process: the 
first one is needs assessment; the second one is capacity 
building; third is planning; fourth is implementation; and 
last, evaluation. This framework ensures the focus of CSAC is 
always current with the local trends and we are being as 
effective as possible with the resources available to us.
    We involve the community in the strategic plan by holding 
monthly meetings to discuss local substance abuse problems, 
emerging drug use trends, designing solutions to address these 
problems, and developing outcomes from programs and projects. 
When needed, task forces and ad hoc workgroups are formed to 
allow individuals to focus on each issue, whether it is 
addressing a specific problem or implementing a project or 
program.
    In addition to the regular meetings, the Clinton Substance 
Abuse Council also conducts focus groups with local law 
enforcement, substance abuse treatment providers, mental health 
providers, human service professionals, and community members. 
When individuals are not available, we also do key informant 
surveys to ensure that we are getting the widest amount of 
information from people and ensuring that people have their 
voice heard.
    CSAC's prescription drug abuse strategic plan works to 
develop social marketing campaigns to change the perception of 
risks associated with prescription drug abuse, implement 
environmental strategies to reduce access to prescription 
drugs--environmental strategies are focused on changing the 
aspects of the environment that contribute to the use of 
drugs--educate the community and target segments on the dangers 
and problems; facilitate participation in the online 
prescription drug tracking system that is currently being 
developed by the State of Iowa, and with these actions we hope 
to increase the perception of harm related to prescription drug 
abuse, reduce the number of people reporting illegal use of 
prescription drugs, reduce the number of people arrested for 
prescription drug abuse, and medical facilities will 
participate in Iowa's online prescription drug trafficking 
system.
    Before I leave, let me just leave you with this. A local 
high school student--let's call him Billy--was caught by his 
mother stealing her heart medication. Billy was crushing this 
medication and snorting it in the hopes of getting high. He 
didn't. Billy's mother became suspicious when she noticed her 
medication was disappearing, and confronted him. He admitted 
his actions. The good news is that Billy is currently receiving 
counseling.
    Thanks for this opportunity to testify.
    Chairman Biden. Thank you.
    [The prepared statement of Mr. Clark appears as a 
submission for the record.]
    Chairman Biden. Ms. Fetko.

  STATEMENT OF MISTY FETKO, R.N., PARENT OF CARL HENNON, NEW 
                          ALBANY, OHIO

    Ms. Fetko. Thank you. My name is Misty Fetko and I'm a 
registered nurse who works in a very busy emergency department 
in central Ohio. But most importantly, I'm a mother of two 
wonderful boys. I am here today to tell you the story of my 
oldest son, Carl. Carl was my beautiful boy, eyes like large 
dark chocolates, an infectious smile, and an insatiable 
curiosity.
    I spent years protecting him from harm, but 4 years ago 
harm found a way to sneak in and steal the life of this gifted 
young man. It was the morning of July 16th of 2003. Carl had 
just graduated from high school and was getting ready to leave 
for Memphis College of Art in 2 days. The college had courted 
him after he had won an award for artwork he created his junior 
year of high school.
    The night before, Carl and I had sat in his room and talked 
with each other about his day at work and the pending trip to 
Memphis. At the end of the conversation, he smiled and hugged 
me. He said, ``Good night, Mom. Love you.'' The next morning I 
decided to walk the dog before waking Carl. By walking next to 
his car, I noticed an empty bottle of Robitussin in his back 
seat. Instantly, I knew something was wrong. I had been very 
vigilant for signs of drug abuse in the past and hadn't seen 
many, but the previous summer I'd found two empty bottles of 
Robitussin in our basement after a sleep-over he had had with 
friends. I knew something was up.
    I rushed to his bedroom door, only to find it locked. After 
finding my way in, I discovered Carl laying peacefully in bed, 
motionless, with legs crossed, but he wasn't responding to my 
screams and he wasn't breathing. I quickly transformed from 
mother to nurse and began CPR, desperately trying to breathe 
life back into my son.
    I could not believe what I had feared most in life had 
happened, but I still did not know what had caused my 
nightmare.
    We are a very close family and I'm a very involved mother. 
Carl had always assured me that he wasn't using drugs or 
alcohol, and I, the ever-watchful mom, believed him as there 
wasn't any evidence to prove differently.
    During Carl's junior year of high school, though, I found 
the first evidence of marijuana in his room. After all the 
talks and reassurances between us, what had changed? I 
intervened and didn't see anything else suspicious until that 
summer when I found those two empty bottles of Robitussin in 
our basement. I was determined to keep drugs out of our house. 
But cough medicine?
    I went to search for answers on the Internet and found 
nothing, and then confronted my son. Carl explained that he and 
his friends had heard you could get high off of cough medicine 
and had tried it, but nothing happened. I was reassured once 
again that he wasn't using hard drugs and not to worry. Finding 
no further evidence, I believed him.
    During his senior year, we had some incidents with his 
interest that he had developed with marijuana, but I thought we 
were doing what we needed to to address this problem. So why, 
on that dreadful July morning, did I discover that my son had 
passed away during the night? Over the next several months 
after his death, I frantically searched for answers. What signs 
did I miss? During my search, I found two more empty bottles of 
Robitussin, but it wasn't until after talking to his friends 
and finding journal entries on his computer that I discovered 
that Carl had been abusing cough medicine intermittently over 
the past two and a half years.
    He documented his abuse in his computer journal. Through 
the Internet and through his friends, he had researched and 
educated himself on how to use these products to get high. He 
wrote about, and enjoyed, the hallucinations achieved upon 
intentionally overdosing on cough and cold products. He 
described the pull that he felt toward the disassociative 
effects of abusing cough medicine and seemed to crave these 
effects.
    According to his journal, he had gradually increased the 
amount of cough medicine he was abusing from 4 ounces to 12 
ounces. As his abuse increased, many things in his life were 
changing; graduation, college, his parents' divorce, and 
increasing pressures in life. I wouldn't find out until the 
morning of his death what he and many others knew about his 
abuse of cough medicine.
    The danger that I so desperately had tried to keep out of 
our house had found a way to sneak in, though the signs at the 
time did not indicate what I knew as signs of drug abuse, as 
there were no needles, there were no powders, there were no 
smells, or large amounts of money being spent, none of the 
typical signs that I associated with drug abuse.
    Carl's autopsy report revealed that he had died from a 
lethal mix of drugs: fentanyl, a strong prescription narcotic, 
cannabinoids found in marijuana, and dextromethorphan, or DXM, 
which is the active ingredient in cough medicine, were found in 
his system. To this day, I don't know where he obtained the 
fentanyl patch. There were no journal entries that talked about 
his use of painkillers. I don't know if this was his first time 
or why he made the wrong choice to abuse prescriptions and 
over-the-counter drugs. I only know parts of his story by the 
words he left behind in his journal. His words are now silent.
    Abuse of over-the-counter and prescription drugs is a very 
large and very concerning problem. We are seeing more teens in 
our emergency departments who are overdosing on these drugs. It 
is becoming more of a norm for us to see than an exception. A 
couple of weeks ago, a young man was brought into our emergency 
department who was at the home of a friend. They had found him 
unresponsive and barely breathing. The paramedics rushed him to 
the hospital. He had been chewing on a fentanyl patch. Several 
unopened patches were found in his pants pockets.
    Just a couple days ago, a young lady was brought in from 
high school, where she had taken 30 Coricidin cough and cold 
tablets that morning at school just to get high. She spent the 
next several days in our intensive care unit. These are just a 
couple of stories of the stories I see daily in our emergency 
department.
    I want to thank you for inviting me to share Carl's story. 
If loving Carl were enough, he would have lived forever. It is 
now with this love that I tell his story so others are aware of 
the grave dangers of this type of drug abuse.
    Thank you very much.
    [The prepared statement of Ms. Fetko appears as a 
submission for the record.]
    Chairman Biden. Thank you.
    Let me start with you, Ms. Fetko. In your attempt to sift 
through the pattern your son got into, did his friends or 
anything reveal how the progression took place from cough 
medicine to fentanyl? I mean, was it sort of part of the 
culture among his friends?
    Ms. Fetko. What I was able to discover, through the journal 
entries and through talking to some of the young men that were 
his friends, it seemed like the cough medicine was what they 
first became attracted to. It sounds like the first experience 
with it after they had heard about it and read about it on the 
Internet, they had actually gone to a local grocery store and 
stole a four-ounce bottle to try it, is what his journal entry 
talks about.
    Really, the journal entries really focused on his use of 
the cough medicine and the hallucinations that he was achieving 
from overdosing on it. It seems like the group of friends had 
discovered this and developed an interest in it, but there 
wasn't any talk about any other drugs at the time, except for 
the marijuana that I had found.
    Chairman Biden. Gentlemen, is Ms. Fetko's story remarkably 
different from what you have become aware of and associated 
with in your work in Clinton and all the work done by the drug 
council?
    Mr. Pasierb. Unfortunately, we get far too many parents 
that contact us through our web site or call the Partnership 
and tell very similar stories, or not of kids who have died, 
but kids who are in the hospital or kids who are now profoundly 
addicted and in treatment centers. If you just took those 
alone, those would be warning signs that something is going on, 
let alone the research that we have.
    Chairman Biden. Mr. Clark.
    Mr. Clark. We haven't had any fatalities yet. But the way 
that the numbers are going and what we're learning now, it may 
be only a matter of time. So, we're very concerned.
    Chairman Biden. The focus of The Partnership for a Drug-
Free America on this issue is to focus on--you do multiple 
things, but focus on educating parents. Is that right?
    Mr. Pasierb. Primarily we're going after mom and dad, 
because what we find in the research--or whoever that adult is 
in a kid's life--is they're actually behind the kids. We get 
about 60 percent of kids who understand this issue that know 
that it goes on, have heard it's happening, whereas, when we 
look at very similar studies around mom or dad or grandma and 
grandpa, whoever that caring adult is, they don't understand 
this. As I said in my testimony, we have the most drug-
experienced generation of parents in history, is one way to 
look at it. This behavior did not go on when they were in high 
school in the 1980s or the early 1990s, it was cocaine or 
things like that.
    So what we see, is parents saying, yes, I'm having these 
conversations with my kid. They tend to overestimate those. But 
when you dig deeper, you find that prescription drug abuse/
over-the-counter medicines don't enter into most of those 
conversations. So mom and dad are well behind their kids. Kids 
know this is going on. They're finding it on the Internet. 
They're seeing it in chat rooms. They're Googling ``cheap way 
to get high'' and getting 10,000 web sites that offer to sell 
them something. So for teenagers, this is pretty omnipresent in 
their lives.
    As we've seen in our research, they're getting very 
tactical in how they use them. The kids that we saw in some of 
our qualitative studies would tell you they are not a drug 
abuser, they are not a drug user, they simply get other 
people's Ritalins because it helps them get better grades, and 
isn't that what they're supposed to be doing? So they're 
looking at this in a very, very different way.
    So, those kids need to be met by a mom and dad who 
understand this in some way, shape, or form, so we really 
believe that we have got to make some headway with parents and 
get them engaged in this, help them understand they've got to 
safeguard their medication, they've got to educate themselves, 
and then they've got to get out with their kids and deliver a 
very strong message that this is not a safer way to get high.
    Chairman Biden. Mr. Clark.
    Mr. Clark. Yes. Actually, I sit on the Board of Directors 
for The Partnership for Drug-Free Iowa, so we work closely with 
the material that they do, because we don't want to create 
material that is already out there when we can be better using 
our time. So, like I talked about that we do social marketing 
campaigns, what we try to do is work with the youth or with the 
targeted area we want to address. Let's say we're working with 
the youth on this one. We're going to pull in a group of youth 
to help create a marketing campaign, a social marketing 
campaign, which is pretty much the same principles as a 
marketing campaign, a general one selling a product. We're 
selling a product, change of social norms, you know the risk of 
use.
    So we're pulling these youth in to create a campaign to 
target their friends, their peers. And not only are we changing 
and educating those youth working on the campaign, but then 
they're going to go out and they're going to deal with their 
friends, their social network and change the norms, perception 
of risk related to prescription drug and over-the-counter drug 
abuse.
    Then not only are we working with youth, their peers, but 
we're also working towards community-level change by creating 
this campaign that is then working with the community trying to 
market these youth on changing their social norms, their 
perception of risk.
    Chairman Biden. What do these kids talk about? Look, this 
is, in my view, incredibly complicated, but not complicated. I 
mean, there is always a social structure that revolves around 
the social setting in which these kids act, whether it's their 
attitude toward sex, their attitude toward drug abuse, or their 
attitude toward studying.
    Is there a difference between the kids who are using street 
drugs and--there are still a lot of street drugs out there. 
It's down, but there's still an unacceptably large number of 
kids in high school who are using cocaine. There are still a 
large number of kids who are abusing speed, methamphetamine, et 
cetera.
    Are they a different, in a sense, clique of kids? I mean, 
do you find that kids who abuse prescription drugs or over-the-
counter medicines, do they think themselves different than the 
kid, the four kids who are getting stoned in the back of the 
school, or getting high on speed, you know, or showing up at 
parties where it's open and notorious use of these drugs? I 
mean, what's the mind-set of the kids in the street or the kids 
in the classroom?
    Mr. Pasierb. All these kids share that common, it's not 
going to be me, I can handle this, I can do this. I can go out 
and I can try it. When you get back to the research that's been 
done, perception of risk, social disapproval, whatever you want 
to call it, one way that we're beginning to think about this is 
it isn't that they're gateway drugs as much as there are 
gateway attitudes. Young people come into society and they say, 
look, I get great grades, I want better grades, I can use 
prescription drugs. Or I have nothing to attach to in society, 
so I'm going to try meth because it'll make me feel perked up.
    It's these attitudes they bring which are interrelated and 
complicated, and we've only really begun to understand what 
causes them to make that decision the first time when somebody 
comes in and says, here, try this with us, do this. What they 
bring to them, the perception of risk, the social disapproval, 
the feelings that they can get away with it, their own personal 
feelings of--
    Chairman Biden. Talk to me about the social disapproval 
piece of it?
    Mr. Pasierb. Pardon me?
    Chairman Biden. Talk to me about the social disapproval 
piece. I remember back in the 1980s, and actually in the 1970s 
and 1980s you could show up certain places. If someone in a 
high-end neighborhood, young professionals were having lunch on 
Monday in the early 1980s and said, I did a line of coke at so 
and so's place, they'd say, OK, all right, I don't do that, but 
what's the big deal? Whereas, no one is going to sit down and 
say that today.
    Mr. Pasierb. Exactly.
    Chairman Biden. So that is what I'm trying to get at. What 
are the kind of conversations? Like, your son's friends are not 
likely to say, you know, I tell you what, man, I've got some of 
the purest stuff I ever had before, man, heroin. This stuff I 
got was really pure. They're not going to sit around your 
basement and talk about that, probably, those kids.
    But would they sit around and say, man, I've figured out 
how to mix this stuff, or I've figured out how to extract this 
stuff? I mean, is there a social acceptance that is broader in 
this area than there is, and how much of the moral 
disapprobation of society, their peers, their teachers, their 
parents, is real? I can remember the lovely, brilliant woman 
sitting behind you who used to work for me and do all this. I 
remember her producing the study for me early on, where we 
started off in hearings a decade ago saying, this ain't your 
mother's marijuana. The marijuana that my generation used in 
the 1960s ain't nothing like the marijuana that's available 
today. And yet, parents back then, the parents of the kids who 
were teenagers in the 1980s, said, well, thank God they're only 
using marijuana. Thank God that's all it is, because, man, they 
could really be doing something bad.
    Our parents say the same thing now. When you confront a 
parent--not confront. A parent finds out his kid is abusing 
cough medicine, is the response, well, thank God it's cough 
medicine and not whatever? I mean, talk to me about--don't talk 
to me like a manager, talk to me like somebody when you deal in 
the neighborhood, when people come in to talk to you. What do 
they say to you? How do they view it? Do they view it with 
alarm or do they view it as--in a sense, Misty, you said--
excuse me for using your first name. You said, well, you know, 
it was cough medicine, at least it wasn't--or at least you 
implied, it wasn't something really bad.
    Ms. Fetko. Exactly.
    Chairman Biden. What was your attitude?
    Ms. Fetko. Exactly. At first, I thought maybe it was 
possible that there was still alcohol in cough medicines, which 
I thought had been removed. Then when I went to the Internet 
and I didn't find anything, I mean, I was, I was relieved. I 
was relieved there weren't syringes. I was relieved there 
wasn't powder. And, you know, here I work in a busy emergency 
department. I should have had my finger on the pulse of the 
changing environment, and we hadn't even been seeing it or 
hearing it there. So I did, I felt a sigh of relief. But I 
think the boys also saw it--and these were very intelligent, 
gifted young men.
    I think the fact that they didn't have to have a drug 
dealer to get it, it wasn't shady, they weren't uncomfortable 
about doing it. Carl wrote about the first time that he had the 
nerve to walk in and purchase it at the drug store. I mean, I 
don't think they associate the same feelings that they do with 
the illegal street drugs.
    Mr. Clark. Another problem is, it's readily available. Say 
a high school student can go to high school and they could get 
some Ritalin from their buddy at school because they may have 
it because it's prescribed and no one is going to say anything. 
So another issue to consider is, the schools are also having to 
address this problem. How exactly do they want to handle 
prescription drugs? Do they want, all drugs have to be checked 
in to the school nurse?
    Then that brings up another issue. What if the student runs 
out of medication, they don't bring it in? There's a lot of 
things that right now are being discussed and trying to figure 
out because this is such a relatively new problem, and it has a 
lot of different dynamics to it because these are prescribed. 
The youth or the user does need this medication, but then if 
the schools don't regulate it, these students have the 
medication at school and they may be distributing them, selling 
them, or just sharing.
    Chairman Biden. I thought it was pretty instructive, the 
comment made by NIH. They got a call from a professor saying, 
it reminded me of the hearings I held on steroids. The hearings 
I held on steroids were, athletes like me resented the hell out 
of the fact that somebody, with one-tenth the work, was getting 
twice the muscle mass and maybe would take my job on the team. 
I found it interesting, the comment made, one student 
complaining to a professor that he was at an intellectual 
disadvantage in class, and his grades, because of the use of--I 
don't know which drug she said. Whatever.
    Mr. Pasierb. We're hearing those exact same things, both 
from college kids and high school kids, from a very competitive 
nature. I'm here to compete, I'm here to get better grades, a 
better job, and I resent those people who may be using it, 
therefore I feel drawn to it. We're stunned when we pull 
parents together and they begin with this disbelief. We're here 
to talk about prescription drug abuse. Oh, you mean if the 
label says take two you take two, not three? No, about taking 
six and chasing them down with alcohol. No, that doesn't go on, 
is the reaction. No, that doesn't happen. They begin to try to 
disabuse us that such a thing would happen in society.
    So you go from this disbelief to almost a relief. Well, 
it's prescription drugs. They're safer. They're made in sterile 
labs, the doctor prescribes those. That's much better than 
cocaine or heroin. Then you begin, as Dr. Volkow did, to help 
us understand: an opioid is an opioid is an opioid, and they're 
shocked and then they want to leave. Then they want to go home 
and take an inventory of their medicine cabinet and talk to 
their kid right away. We need to kind of take that ``in'' of 15 
parents in a focus group and get it out to 15 million parents, 
and 150 million, to help them understand that they're in a 
unique position on this. They can control supply, unlike any 
aspect of the drug issue, control it in their own home and open 
up their radar to it, and they can control demand by engaging 
their kid and helping them understand, this is not only safer, 
it is extraordinarily dangerous. This is Russian roulette on a 
scale we haven't seen before.
    Chairman Biden. The last question I have. I realize I'm 
just asking you from your experience base, which is extensive, 
from the early 1990s on. Actually, any one of you can respond. 
First of all, I doubt if there's any data to sustain the 
question I'm about to ask--the answer, I'm implying. But if, in 
fact, figuratively speaking, the medicine cabinet is closed, 
there is no access at the drug store over the counter, is the 
same kid who would be inclined to go that route just going to 
turn around and go to the street?
    The kid who wants to abuse Oxycontin, the kid who wants to 
abuse cough medicine, the kid who wants to abuse whatever the 
over-the-counter prescription drug is, is it just that it's 
easier to get there and that kid--I'm going to say something 
really ridiculous-sounding: abuse of prescription drug is up 
among teenagers, other drugs are down. Is it because that if 
you didn't have this abuse, would those other drugs of choice, 
street choice, would they be back up where they are? Do you 
understand the point I'm trying to make?
    Mr. Pasierb. Yes. Yes. We're not seeing this as a 
replacement, I'm doing this instead of that. None of the data 
are showing this. We're seeing that for some kids it's a bridge 
between the casual alcohol and marijuana user, to then adding 
these on and then moving on to other drugs. So if from a 
bridging standpoint on that ladder of drug use, this behavior 
appears to be there.
    But your earlier question, we believe right now all the 
studies we're doing is showing only about 1 percent of kids are 
getting these drugs from the Internet. I would wager that if we 
truly did lock down the medicine cabinets and we really did 
limit that supply, these kids would migrate to the Internet 
because supply is there, at least on some of the lesser opioid 
products.
    We don't know if a kid who becomes a dedicated user, who 
exhausts mom, grandma, dad, and all those other and friends, 
whether or not he or she, four or five steps down, doesn't turn 
to the Internet. I believe, as long as there is a demand, 
supply finds a way and we've got to go after that demand, 
otherwise these kids, as motivated and as intelligent as they 
are, will find ways.
    Chairman Biden. I appreciate that.
    Does anyone have a closing comment you'd like to make? With 
your permission, I have several questions on behalf of several 
of my colleagues, and myself as well--I'm not going to burden 
you with a whole lot of questions--in writing that I'd like to 
be able to submit to you, if that's OK.
    [The questions appear as a submission for the record.]
    Chairman Biden. Did anyone have any closing comment?
    Mr. Pasierb. I just want to thank you for forcing this on 
the national agenda, because it needs to get high up on the 
agenda. Methamphetamine is a huge problem in parts of our 
country, other drugs are huge problems. This seems to be a 
universal issue from Maine to Florida, Hawaii, and every point 
in between, and we've really got to help the country understand 
that this falls into that classic, this is a preventable 
behavior, and where kids end up in trouble, this is a treatable 
addiction, but we've got to get this out there.
    Chairman Biden. Well, I thank you all. I particularly thank 
you, Mrs. Fetko. Like I said, I just think it takes a special 
kind of person to be able to, in effect--I watched you as you 
read your statement. It's always present.
    Ms. Fetko. Thank you.
    Chairman Biden. So I thank you for your courage and thank 
you for your willingness to share with us.
    I know you know, Steve, we'll be back to you for additional 
help here.
    Mr. Pasierb. Yes.
    Chairman Biden. This is the beginning of this process, not 
the end of it. I thank you for making the trip in.
    As Senator Grassley says, his office is yours for as long 
as you are here, and maybe I could talk to you about how to 
vote, OK?
    [Laughter.]
    Thank you all very, very much.
    [The prepared statement of Senator Leahy appears as a 
submission for the record.]
    [Whereupon, at 3:51 p.m. the Subcommittee was adjourned.]
    [Questions and answers and submission for the record 
follows.]


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