[House Hearing, 114 Congress]
[From the U.S. Government Publishing Office]


     ADDRESSING VA OPIOID PRESCRIPTION AND PAIN MANAGEMENT PRACTICES

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

                              FIELD HEARING

                               BEFORE THE

              SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

                                 OF THE

                     COMMITTEE ON VETERANS' AFFAIRS
                     U.S. HOUSE OF REPRESENTATIVES

                    ONE HUNDRED FOURTEENTH CONGRESS

                             SECOND SESSION

                               __________

                         FRIDAY, MARCH 4, 2016

              FIELD HEARING HELD IN CONCORD, NEW HAMPSHIRE

                               __________

                           Serial No. 114-58

                               __________

       Printed for the use of the Committee on Veterans' Affairs
       
       
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                    COMMITTEE ON VETERANS' AFFAIRS

                     JEFF MILLER, Florida, Chairman

DOUG LAMBORN, Colorado               CORRINE BROWN, Florida, Ranking 
GUS M. BILIRAKIS, Florida, Vice-         Minority Member
    Chairman                         MARK TAKANO, California
DAVID P. ROE, Tennessee              JULIA BROWNLEY, California
DAN BENISHEK, Michigan               DINA TITUS, Nevada
TIM HUELSKAMP, Kansas                RAUL RUIZ, California
MIKE COFFMAN, Colorado               ANN M. KUSTER, New Hampshire
BRAD R. WENSTRUP, Ohio               BETO O'ROURKE, Texas
JACKIE WALORSKI, Indiana             KATHLEEN RICE, New York
RALPH ABRAHAM, Louisiana             TIMOTHY J. WALZ, Minnesota
LEE ZELDIN, New York                 JERRY McNERNEY, California
RYAN COSTELLO, Pennsylvania
AMATA COLEMAN RADEWAGEN, American 
    Samoa
MIKE BOST, Illinois
                       Jon Towers, Staff Director
                Don Phillips, Democratic Staff Director

              SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATION

                    MIKE COFFMAN, Colorado, Chairman

DOUG LAMBORN, Colorado               ANN M. KUSTER, New Hampshire, 
DAVID P. ROE, Tennessee                  Ranking Member
DAN BENISHEK, Michigan               BETO O'ROURKE, Texas
TIM HUELSKAMP, Kansas                KATHLEEN RICE, New York
JACKIE WALORSKI, Indiana             TIMOTHY J. WALZ, Minnesota

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
official version. Because electronic submissions are used to prepare 
both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.
                            C O N T E N T S

                              ----------                              

                         Friday, March 4, 2016

                                                                   Page

Addressing VA Opioid Prescription and Pain Management Practices..     1

                           OPENING STATEMENTS

Mike Coffman, Chairman...........................................     1
Ann M. Kuster, Ranking Member....................................     2
Honorable Frank Guinta, U.S. House of Representatives, 1st 
  Congressional District; New Hampshire..........................     4

                               WITNESSES

Mr. Peter Kelleher, Chief Executive Officer, Harbor Homes........     6
    Prepared Statement...........................................    26
Ms. Christine Weber, Director of Substance Abuse Services, Easter 
  Seals Farnum Center............................................     8
    Prepared Statement...........................................    27
Mr. Joseph Foster, Attorney General, New Hampshire Department of 
  Justice........................................................    10
    Prepared Statement...........................................    28
Julie Franklin, M.D., Pain Medicine Practitioner, White River 
  Junction, VT, VA Medical Center................................    13
    Prepared Statement...........................................    29

        Accompanied by:

    Grigory Chernyak, M.D., Chief of Anesthesiology, Manchester, 
        NH, VA Medical Center

 
    ADDRESSING VA OPIOID PRESCRIPTION AND PAIN MANAGEMENT PRACTICES

                              ----------                              


                         Friday, March 4, 2016

             U.S. House of Representatives,
                    Committee on Veterans' Affairs,
                                  Subcommittee on Oversight
                                        and Investigations,
                                                   Washington, D.C.
    The Subcommittee met, pursuant to notice, at 10:30 a.m., at 
National Guard Headquarters, 1 Minuteman Way, Concord, New 
Hampshire, Hon. Mike Coffman [Chairman of the Subcommittee] 
presiding.
    Present: Representatives Coffman and Kuster.
    Also Present: Representative Guinta

           OPENING STATEMENT OF CHAIRMAN MIKE COFFMAN

    Mr. Coffman. Good morning. This hearing is to come to 
order.
    I want to welcome everyone to today's hearing on opioid 
addiction and VA's implementation of alternative treatments for 
chronic pain. First, as a preliminary matter, I would like to 
ask unanimous consent that Representative Frank Guinta be 
allowed to join us on the dais today.
    Hearing no objection, so ordered.
    I would like to begin by putting today's hearing in 
context. According to media reports, in 2003 the Los Angeles 
listed Dr. John Sturman, Jr. in its section on ``bad docs.'' 
That same year, the Medical Board of California reported 
administrative actions against Dr. Sturman for failures 
pertaining to a controlled drug. In 2012, Dr. Sturman's medical 
privileges were reportedly suspended after a number of patients 
died due to opiate-related prescriptions while under his care.
    In April 2015, Dr. Sturman was hired by VA, and by August 
2015, Dr. Sturman was arrested at the VA Medical Center in 
Danville, Illinois due to the many years of investigative work 
by Indiana's Medicaid Fraud Control Unit. Dr. Sturman is now 
facing multiple felony charges for over prescribing narcotics 
related to pain management. In all, media reports that 
``Fifteen patients died of overdose or toxicity within a month 
of receiving treatment from Dr. Sturman between 2009 and 
2015.''
    It is bad enough that VA did not properly review Dr. 
Sturman's history before hiring him, but what makes this issue 
even more egregious is that with nearly a decade of public 
failures related to opiates, Dr. Sturman was hired to be the 
chief of opiate safety.
    Now, looking at opiate safety from a broader perspective, 
according to an inspector general's report issued in May 2014, 
more than 50 percent of the veteran population experiences 
chronic pain. VA's response to chronic pain has mainly been 
prescribing larger amounts of opioids as evident in VA's own 
data which showed an increase of 77 percent between 2004 and 
2014 in VA outpatient care.
    In 2013, VA unveiled the Opioid Safety Initiative, which 
was supposed to promote alternative methods of pain control 
such as acupuncture and chiropractic care while reducing the 
dosages of prescriptions for opioid medications. But I am 
concerned that VA's promotion of alternative methods of pain 
control may be limited. According to the National PTSD Center, 
VA states that, ``Most Medicaid Center of Mental Health 
Programs offer alternative therapies,'' but it's the qualifier 
most that has me concerned.
    One of the issues I want to get into today is how VA's 
central office captures data on efficacy of alternative 
treatments. As we talked about in our hearing on this topic on 
June 10th, 2015, there have been countless examples of veterans 
being over medicated or experiencing adverse drug reactions due 
to improper treatment or nonexistent monitoring.
    We know that some VA medical centers are exploring new ways 
of controlling chronic pain. According to an article published 
in April 2015, the Bronx VA is focusing on physical 
rehabilitation, and that effort has resulted in the lowest rate 
of opiate prescriptions in any hospital in the VA health care 
system. Likewise, the VA Medical Center in White River Junction 
is said to have designed programs to relieve pain without 
strong medications, to include acupuncture, yoga, and aquatic 
therapy as alternatives. However, what is unclear is whether or 
not this effort is managed at VA Central Office, and how best 
practices are implemented or shared across the VA.
    The Department cannot simply introduce well-intended 
programs and then fail to manage them properly. If these 
alternative treatments truly work, they need to be implemented 
throughout VA and not merely be relegated to a SharePoint 
server for others to access if they are interested.
    With that, I now yield to Ranking Member Kuster for any 
opening remarks that she may have.

       OPENING STATEMENT OF ANN M. KUSTER, RANKING MEMBER

    Ms. Kuster. Well, thank you, Chairman Coffman, and thank 
you for being with us here in New Hampshire. I just want to 
express my appreciation for bringing the House Veterans' 
Affairs Oversight and Investigations Subcommittee to New 
Hampshire. It is a great honor for me to have you here, and 
thank you, Mr. Guinta for joining us.
    I want to thank all of our witnesses who are here with us 
today and express my pride that New Hampshire and, in 
particular, our White River Junction VA, right on the border 
with Vermont, but serving New Hampshire patients and 
Manchester, both have stories to tell that we can share across 
the VA to make sure that we are treating veterans both for 
managing their pain and to make sure we bring down the rate of 
opioid use.
    You know, this is a big issue. I do not need to remind 
anyone in the audience from New Hampshire this now polls as the 
number one issue in New Hampshire for voters and constituents 
in terms of their concern above even the economy and jobs. Tim 
Rourke of our Governor's Commission on Alcohol and Drug Abuse 
has stated, ``No group is immune to it.'' It is happening in 
our cities, our rural areas, and our affluent communities.
    And I have been traveling for the year through the 2nd 
Congressional District bringing together community groups, 
treatment providers, hospital, physicians, mental health 
providers, veterans organizations, and law enforcement to try 
to address this at the local level. I have also been involved 
with Congressman Guinta and our bipartisan task force to combat 
the heroin epidemic, and we now have 70 Members of Congress on 
both sides of the aisle who are concerned about the heroin use 
in their districts and about how we can do better.
    Some of this, we need to unlock some of the inadvertent, 
probably well-intended public policies of the time, but there 
are unintended consequences, and we need to unlock and unravel 
those along the way. We need to make sure that people have 
access to treatment, to lifelong recovery, and, of course, we 
need to support our law enforcement.
    In New Hampshire alone, we had last year 420 opioid related 
deaths, up from 326 the year before. Tragically, more people 
die from overdoses than in car accidents, and this is an 
astonishing fact. In New Hampshire, we are nearly 4 times more 
likely to die from an opioid overdose than a car accident. 
Think about that, 4 times.
    Across the country, nearly 260 million prescriptions were 
written for opioids, enough, according to the Centers for 
Disease Control, for every American adult to have their own 
bottle of pills. And we hear stories every day about people 
getting surgery, car accidents, OB, having a baby by cesarean, 
or even dentistry.
    Part of the stories are young people, teenagers, who are 
going to get their wisdom teeth removed, and walking out with 
30 Percocet. So we have got to do better. And as always, as we 
look for a way to address the epidemic, we need to call upon 
all of our citizens and all our institutions to come together. 
As many in the room know, while our State has one of the 
highest rates of addiction in the country, we are sadly second 
to last in access to treatment. The Granite State spends only 
$8 per capita on treatment for substance abuse.
    One of the issues that I want to address is try to get 
upstream on this issue. So this morning we will hear about the 
severity of the epidemic and how the veterans community has 
been especially hard hit, but how the VA and the veterans 
community of treatment can be on the cutting edge and bring 
solutions to our civilian health care, as well as obviously to 
help veterans who have been historically prescribed opioid at a 
much, much higher rate, and often, as the chair pointed out, to 
manage chronic pain.
    There is growing awareness that the long-term prescription 
of opioids to manage chronic pain can have severe and sometimes 
tragic consequences. It has been reported that veterans are 
twice as likely to die from accidental overdose compared to 
non-veterans.
    The good news is that the VA has shown success in reducing 
the amount of opioids prescribed to veterans, but I share the 
chair's concern that without access to effective alternative 
treatments and therapies to manage chronic pain, access to 
mental health services, and access to substance abuse treatment 
for veterans who become dependent upon prescription opioids, 
that veterans may illegally obtain and abuse opioid 
prescriptions, heroin, and fentanyl because they are not 
receiving the care that they need.
    As part of that care, we need to understand and spread the 
use of alternative treatments and better pain management 
techniques. We hear reports that veterans with chronic pain are 
sometimes unable to receive alternative treatments, such as 
acupuncture therapy, or are unable to get recurring 
appointments at VA pain clinics. We also hear reports of 
veterans who struggle with substance use or addiction issues, 
and they sometimes have to wait months to receive treatment. 
This is simply unacceptable.
    I was proud to join Congressman Guinta in helping to 
introduce, and I believe Congressman Coffman as well, the Jason 
Simcakoski Promise Act, which would help improve opioid 
prescription practices at the VA. And our Full VA Committee 
passed this out of Committee unanimously last week, and it sent 
the bill the House floor with our approval. But much more still 
needs to be done.
    One of the issues that I would like to focus on this 
morning, is how the VA can better share practices in pain 
management techniques across the country. This is an ongoing 
concern with the VA. We know that innovative treatments are 
being developed, but they are in one area, and I am proud to 
say one, we need to share them throughout the rest of the 
system.
    We will hear today about successful programs to manage and 
treat chronic pain in Manchester and White River Junction. We 
will also hear from great programs at Easter Seals of New 
Hampshire and Harbor Homes, two organizations providing 
treatment to their veterans struggling with substance use 
issues and opioid dependence.
    And finally, we must explore how we can quickly and 
effectively implement the best pain management opioid 
prescription monitoring practices used at Manchester and White 
River Junction VA at facilities all across the country to 
prevent veterans from becoming addicted to opioids. I want to 
know how the VA community providers and State and local 
governments can come together to get veterans struggling with 
opioid addiction the most effective treatments they need, and 
then share these best practices with communities all across the 
country.
    We will not solve the opioid use epidemic in New Hampshire 
or in the country or help our veterans without dedicated and 
coordinated efforts. And for that, I thank you, Mr. Coffman, 
our Chairman, for coming to New Hampshire, and I yield back.
    Mr. Coffman. Thank you, Representative Kuster, Ranking 
Member. We will now recognize Representative Guinta for 5 
minutes for his opening remarks.

          OPENING STATEMENT OF HONORABLE FRANK GUINTA

    Mr. Guinta. Thank you, Mr. Chairman. Thank you for the 
opportunity to participate in this event here in New Hampshire. 
I appreciate the opportunity for the Subcommittee to address VA 
opioid prescription and pain management practices. This is 
something that has clearly become a critical issue not just 
within the VA community, but in the community at large.
    I want to thank the Subcommittee for its diligent work on 
the issue. I want to thank my colleagues, the Chairman of the 
Subcommittee, Mr. Coffman, and the Ranking Member, my colleague 
from New Hampshire, Ms. Kuster, for her work and for our work 
in the bipartisan Congressional Task Force to combat heroin and 
opioid use.
    She mentioned that we have upwards of 70 Members now on the 
task force. That is, I think, indicative of the importance that 
Congress is placing on this issue. When we began this effort a 
year ago, we had to explain in many circumstances the 
importance of why Congress needs to be engaged. Today, 
fortunately, so many Members appreciate the concern, not just 
here in New Hampshire, but all across the country. This is an 
epidemic that we have to fight. This is an epidemic that we 
will win.
    But having opportunities like this to bring the Committee 
to New Hampshire, to see firsthand what we are doing, utilize 
best practices, and improve also what we are doing, I think, is 
critical. So I thank you both for your time and your tireless 
effort.
    I have spent quite a bit of time talking with New Hampshire 
veterans, New Hampshire civilian individuals who are impacted 
by opioid use, either over prescription management. And I find 
that we are at a point where we need to not only review our 
practices, but we need to pay close attention to the practices 
we currently utilize, because unfortunately in some 
circumstances, we may be falling short.
    I know here in New England we strive to achieve the best 
and highest quality of medical care for our veterans. Our 
veterans here in New Hampshire who have a great opportunity and 
great energy in working with us on this issue continue to want 
to press our VA system in the region to be the best it can be. 
And this hearing, I hope will entertain opportunities for us to 
make those options better.
    I know that over the years in different parts of the 
country there has been a lot of critique and criticism of the 
VA system. We are here to try to make sure that we protect the 
good parts of it and improve those areas that need to be 
improved, because ultimately the quality and care of our 
veterans is what is most important to me and to this Committee.
    But seeking alternative treatment to opioid use is 
something that we must shed a greater light upon. For years, 
opioid use has been the primary practice, not just within the 
VA system, but outside of the VA system, for pain management. 
And we have now seen the challenges that it has created. I 
think a multipronged approach, whether it is within the VA 
system or outside of the VA system to ensure that we provide 
proper medical access through drug treatment programs, through 
recovery or drug courts, is incredibly important, and one of 
the only ways we are going to try to help manage addiction.
    But also on the public safety and criminal side, focusing 
all of our efforts on making sure that those who are breaking 
the law, particularly in the areas of distribution, pay the 
full price. That debate will continue here in New Hampshire and 
around the country.
    I will be visiting the border next month to get a better 
sense of how illicit and illegal drugs are coming through the 
border. After briefings with the DEA, I am shocked and 
disturbed about the mechanisms that people like El Chapo and 
others have used to bring drugs into our country. This is 
something that we are committed to stopping in Congress, and I, 
again, very much appreciate the Chairman, Mr. Coffman, and the 
Ranking Member, Ms. Kuster, for their attention not just on the 
Committee, but within the task force as well.
    And I yield back.
    Mr. Coffman. Thank you, Mr. Kuster. Mr. Guinta.
    I would like now to introduce our panel. On the panel we 
have Mr. Peter Kelleher, Chief Executive Officer of Harbor 
Homes; Ms. Christine Weber, Director of Substance Abuse 
Services at the Easter Seals Farnum Center; the Honorable 
Attorney General, Joseph Foster, New Hampshire Department of 
Justice; and Dr. Julie Franklin, pain medicine practitioner at 
the White River Junction, Vermont VA Medical Center, who is 
accompanied by Dr. Grigory Chernyak, chief of anesthesiology at 
the Manchester, New Hampshire VA Medical Center.
    I ask the witnesses to pleased stand and raise your right 
hands.
    [Witnesses sworn.]
    Mr. Coffman. Thank you. Please be seated. And let the 
record reflect that all of the witnesses have answered in the 
affirmative.
    Mr. Kelleher, you are now recognized for 5 minutes.

                  STATEMENT OF PETER KELLEHER

    Mr. Kelleher. Thank you, Mr. Chairman, and thank you, 
Congresswoman Kuster, and other distinguished Committee 
Members.
    Mr. Coffman. Could you please move the microphone a little 
bit closer to you? Thank you. If somebody could assist that. 
Thank you.
    Mr. Kelleher. Thank you. Thank you, Mr. Chairman, and 
Congresswoman Kuster, and other distinguished Committee Members 
and guests for this opportunity to address this important issue 
that is plaguing our veterans and their families. In my role on 
the Federal Secretary of the VA's Advisory Committee on 
Homeless Veterans, we have discussed a wide range of topics on 
homeless veterans, and I look forward to delving further into 
this conversation.
    I am here representing Harbor Homes, Keystone Hall, and 
other Partnership for Successful Living agencies, a 
collaboration of six nonprofits in the greater national area 
that integrate care on the topics of homelessness, behavioral 
health care, and primary health care. We offer over 80 programs 
and operate a federally-qualified health center for low income 
and homeless individuals where we often serve veterans who may 
not qualify for VA health care.
    We operate eight veteran specific programs: supportive 
services for veterans and their families, a highly successful 
homeless veteran reintegration program which provides 
employment service, four grant and per diem programs, and a 
project based VASH program, and also a robust SAMHSA program, 
which provides behavioral health services to veterans as well.
    As a partnership, we offer a myriad of mental health, 
substance use, and dual diagnosis programs, especially out of 
our Harbor Care Health and Wellness Center, a federally 
qualified health center, and Keystone Hall, one of the largest 
substance use providers and treatment centers in the State. In 
our clinic, we offer medication assisted treatment and are 
endeavoring to provide a full range of medication assisted 
treatment services, including methadone, under one roof.
    Data is varying, but our agency staff reports that 
approximately 45 to 65 percent of active veterans we are 
serving are suffering from a substance use disorder, and that 
15 to 25 percent of them are specifically struggling with 
opioid abuse.
    The population of veterans who are willing to reflect 
addiction as a disability on intake into the congressionally 
mandated Homeless Management Information System frequently cite 
both alcohol and drug use. For example, in 2014 and 2015, 99 
percent of the veterans citing substance abuse reported a 
disability with both alcohol and drugs. The majority of 
veterans we work with prefer to admit to alcohol abuse, despite 
their addiction to other substances.
    Our population frequently represents individuals who have 
not been affiliated with the VA health care system, and, 
therefore, have not been prescribed opioids for pain 
management, and instead self-medicate with whatever is readily 
available.
    We have and continue to work in tandem with the VA and 
other statewide veteran-serving organizations to combat the 
substance use crisis. It is indisputable by all veteran-serving 
stakeholders that access to more treatment and more lengthy 
aftercare is critical to solving this opioid crisis.
    Please allow me to offer three suggestions. First, broaden 
access to the VA health care system to serve more veterans; 
second, approval for VA medical centers to provide a full range 
of medication assisted treatment services, such as those 
provided at the VA Causeway Center in Boston; three, 
transitional probationary period of 28 days in the grant and 
per diem programs with co-located outpatient services with 
veterans with substance use disorder who would not be 
successful in the present-day iteration of GPD programs.
    This means that any veteran that goes into a grant per diem 
program has a requirement that is part of the congressionally 
mandated definition of the grant per diem program has to agree 
to go into a sober living environment, which serves maybe 
persons with alcohol abuse a little bit more, and is less 
useful and problematic with people who have opioid addiction.
    Allow me to share a recent story of a veteran challenged by 
his substance abuse who found a path to recovery and 
independence as a result of the veteran services provided by 
Harbor Homes and fellow organizations. Our SSVF and HVRP staff, 
again, worked with the 46-year-old veteran who was not eligible 
for VA services.
    He had been laid off from his job, and then evicted from 
his home rendering him homeless. During the needs section of 
his intake assessment, he disclosed that he was in treatment 
for opioid addiction, and was currently taking Suboxone. The 
SSVF and HVRP staff were able to move him into permanent 
housing with some financial assistance and secure him a full-
time job.
    He received a full benefit package from his employer, which 
came with a very high deductible. Because of the major increase 
in his co-pay for Suboxone treatment through private insurance, 
he could no longer afford it and slipped back into heroin 
again. The veteran was facing eviction from his housing, and 
his job was at risk due to his job performance. They then tried 
to seek through SAMHSA, but because he had been housed through 
SSVF, he couldn't fit into their criteria.
    The SSVF representative knew that Easter Seals had launched 
a new program with Farnum Center and had five beds for 
veterans, and within 2 hours he was admitted. He successfully 
completed the 28-day program, and today is maintaining his 
Suboxone treatment with financial assistance through Easter 
Seals Veteran Account Program, and is maintaining his stable 
housing and employment.
    This story is a clear illustration of how we can move the 
dial with our veterans in crisis when we can rely on each other 
and reach a common goal. I know we all agree on the premise 
that substance misuse among veterans can be the result of many 
interrelated moving parts, struggling with opioid drug usage 
from readjustment challenges back into civilian life, which 
often stem from post-traumatic stress disorder, physical 
injuries, and associated pain management.
    Although more attention is being given to the issue of drug 
addiction among our veteran population, the percentage of 
veterans who seek help is still disturbingly low. In our 
experience, veterans are more apt to avoid mentioning at the 
point of intake that they have a substance abuse addiction or 
that they are currently using for fear of stigma, creating 
barriers to getting help, and housing, especially when they're 
experiencing homelessness.
    From my perspective, to evaluate real change in the lives 
of veterans we serve, we need to look at housing as a critical 
form of health care. By first tending to the veteran's housing, 
we can create one tenable link in the braid that is our 
involvement with their ultimate success.
    Along with other supportive services, we can increase our 
connection with them and can encourage their improved mental 
and physical health, reduce their dependency on substances, and 
increase their earning potential through education and 
employment support. All of this will produce a much higher 
percentage of those who will be able to maintain their 
independence, connect with government and nonprofit services, 
and achieve more successful living.
    Thank you.

    0[The prepared statement of Peter Kelleher appears in the 
Appendix]
    Mr. Coffman. Thank you, Mr. Kelleher, for your testimony 
today.
    Ms. Weber, you are now recognized for 5 minutes.

                  STATEMENT OF CHRISTINE WEBER

    Ms. Weber. Good morning, and thank you. I'll speak as a 
provider of substance abuse disorder treatment, in Manchester, 
New Hampshire, as Ms. Kuster said, the number one public health 
concern for New Hampshire citizens, veterans and civilians.
    The program that I direct in Manchester serves over 2,000 
people a year, and I say ``people'' instead of addicts, or 
alcoholics, or other terms that can be used to really separate 
us here in this room--
    [Disturbance in the hearing room.]
    Ms. Weber. Should I speak up? Is that okay?
    Ms. Kuster. There you go. You are back on.
    Ms. Weber. I am afraid of the microphone now. We are good? 
Okay.
    So as I was saying, I just wanted to use the term 
``people'' because that is who I work with. That is who are 
referred to me, military service Member or other--
    Mr. Coffman. Just one second. Can those in the audience in 
the back hear? Okay, good. Thank you.
    Ms. Weber. Great. Thanks.
    Mr. Coffman. Please proceed.
    Ms. Weber. So my staff is tasked to specifically screen our 
prospective clients by asking the question, ``have you ever 
served in the military,'' because there are differences with 
the citizens that we serve, to inform their care. It is 
critical that treatment providers, first responders, emergency 
departments, and treatment liaisons understand how to move 
forward when a man or a woman answers ``yes'' to that question. 
It is not just asking the question. It is informing care 
afterwards.
    So servicemembers present to treatment with us having 
struggled to navigate when and how to ask for help. If you have 
heard of the difficulties servicemembers face in accessing 
adequate medical surgical care, imagine that struggle and add 
on top of it limited bed availability or substantial substance 
abuse treatment within the VA system.
    For those that are able to identify that they are in need 
of help, the highest hurdle next to accessing care is the 
stigma associated with it. Our clients have been in country, in 
the Yugoslav region, Kuwait, South America, Desert Storm, 
Desert Shield, OIF, OEF, New Dawn, various regions of 
Afghanistan, multiple stations throughout the world. None of 
them imagined the values, conflicts, and the isolative nature 
of returning to the United States and contemplating suicide 
because of their need to access substance use disorder 
treatment.
    Prescribers must take the responsibility of opiate 
prescribing very seriously. Implementing and enforcing 
substance use disorders curricula for students and licensed 
practitioners through continuing medical education is an 
important step in ensuring that physicians are exposed to the 
nature of the biology of chemical dependence. It's my hope that 
the VA and other important health care institutions provide 
their personnel with ongoing and comprehensive training by 
American Society of Addiction Medicine Board, certified peers 
and licensed clinicians, not just their own physicians.
    Physicians in this State have met with New Hampshire State 
Rep Rosenwald to discuss recent bills to include H.B. 1423, 
relative to prescribing practices, as well as the PDMP, the 
Prescription Drug Monitoring Program, in New Hampshire. It's 
concerning to me as a substance disorder treatment provider 
that these efforts might result in legislation that's embraced 
in language only without enforcement or oversight by the Board 
of Medicine.
    Prevention efforts, utilization of the esprit and referral 
process, physician training and coordination access to 
substance treatment, facilities like Vets Choice, are concrete 
actionable steps. I'm happy to say within the last couple of 
days Vets Choice has finally approved Farnum Center and its 
affiliates to be a Vets Choice provider through Medicare. That 
was a substantial hurdle in the credentialing process.
    Regardless of the MOS discharge status for military 
service, we're seeing an increased population in need of 
structured clinical intervention support. Without providers and 
prescribers taking initiative, the mortality rate for this 
chronic and progressive illness will continue to rise.
    Thank you for the opportunity to speak here today. I 
appreciate it.

    [The prepared statement of Christine Weber appears in the 
Appendix]

    Mr. Coffman. Thank you very much for your testimony, Ms. 
Weber.
    Mr. Foster, attorney general for the State of New 
Hampshire, you are now recognized for 5 minutes.

                   STATEMENT OF JOSEPH FOSTER

    Mr. Foster. Thank you, Mr. Chairman, and I do have some 
slides. There we are. Great.
    Like many States, the illegal and prescription drug opioid 
crisis is the most pressing public health and public safety 
challenge facing New Hampshire. It penetrates every aspect of 
our society, all socioeconomic groups, all races, each gender, 
all age groups. And it adversely impacts our neighborhoods, our 
schools, our health care system, our courts, our prisons, our 
first responders, our businesses, and our highways.
    While prescription opioids and heroin remain extremely 
problematic, unlawfully manufactured fentanyl is at the center 
of New Hampshire's epidemic. I am going to show some slides 
that illustrate the depth of the opioid problem here in New 
Hampshire. They were prepared by the State medical examiner, 
who is part of our office, and the Department of Safety that 
houses our State police.
    First slide, please.
    As you can see, and as Congresswoman Kuster mentioned 
earlier, in 2000 we had about 50 overdose deaths, and in 2015, 
420 confirmed with 14 still awaiting toxicology. And I have 
been informed as of late February, we already had 60 overdose 
deaths here in New Hampshire, so the rate is not decreasing.
    Next slide, please.
    15 years ago, there were about twice as many highway deaths 
as overdose deaths. Today there are 4 times as many overdose 
deaths as highway deaths in New Hampshire.
    Next slide.
    The overdose deaths are prevalent in every region of the 
State. This shows places where individuals have fatal 
overdoses. As you can see, it is in the most northern part of 
the State as well as the southern part of the State. It doesn't 
matter what part of the State you are, folks are suffering 
overdose deaths.
    Next slide, please.
    And this shows nonfatal overdoses. Thousands of them have 
occurred statewide. The New Hampshire Bureau of EMS reported 
that in 2015, 4,235 doses are Narcan were administered around 
the State. Sometimes more than one dose is necessary when you 
are dealing with a fentanyl overdose. 1, 2, 3, or 4 can be 
required to bring the person back.
    Next slide, please.
    Now, fentanyl and other agents do not discriminate by age. 
Every age group has experienced sharp increases in overdoses, 
but for the very young, and the very young as you can see from 
that slide.
    Next slide, please.
    Deaths from heroin and fentanyl are fairly new. As you can 
see, a decade ago deaths from heroin were quite rate, and 
fentanyl deaths did not exist at all. That changed and has done 
so with a vengeance.
    Next slide, please.
    This slide here shows the percentages of deaths that were 
caused by fentanyl in New Hampshire. 65 were caused exclusively 
or partially by fentanyl, and we're talking about illegally 
manufactured fentanyl that comes up mostly from Mexico, and 
makes it way often to Lawrence, Massachusetts or New York City, 
and then into our State.
    And you can take the slides down.
    So what actions is the State doing to address the epidemic? 
Very broadly speaking, there's really two areas to address the 
problem. On the supply side, that's mostly a law enforcement 
function, and on the demand side, broadly speaking, a public 
health and education function. We cannot arrest our way out of 
the problem. We need to reduce demand, and with that supply 
will drop. That said, addressing supply and demand both are 
critical.
    There are a number of law enforcement initiative taking 
place within the State and across State lines. This morning I 
was, in fact, talking to Attorney General Healey from 
Massachusetts to try to coordinate around the problem in 
Lawrence. But the problem simply doesn't stop at the State 
borders. Interrupting supply requires cooperation by and 
between our Federal, State, county, and local law enforcement 
agencies, and that is ongoing.
    One initiative recently underway is treating overdose 
deaths as crime scenes. You would think that has happened, but 
it generally has not happened in the past. They're now being 
investigated as a crime scene because a crime has been 
committed there. The goal is to hold those who sold drugs to 
the victim accountable, and also gather information so it can 
get the ultimate source of the drugs and try to disrupt the 
supply into the State.
    A lot has happened on the public health side, and in many 
ways I would say that's more important. In November, our 
governor called for a special session of our legislature. The 
House and Senate convened and passed a bill to form a 25-member 
opioid task force made up of representative and senators. The 
task force worked aggressively over several weeks and came up 
with a number of legislative proposals. Many of those proposals 
were recommended by the governor's office working closely with 
a group of her department heads, who she gets together every 
Wednesday morning. A number of departments are impacted. HHS, 
Education, Corrections, my office, and other departments, we 
meet and we make sure this issue is being moved along. So this 
has been truly a bipartisan effort as it should be.
    Some of the legislation already passed includes requiring 
physicians to query the State's prescription drug monitoring 
program in most instances. Before, they only had to register 
but not use it. And it also requires prescription data to be 
submitted daily. It mandates safe opioid prescribing education 
for prescribers, and it places pain specialists on the Board of 
Medicine to ensure expertise when reviewing treatment providers 
for professional misconduct.
    Legislation that's still in process includes expanding 
funding for our drug courts, reauthorizing New Hampshire's 
Health Protection Plan. That's our unique form of Medicaid 
expansion that was adopted in the State. This is key to 
expanding the State's inadequate treatment network. The plan 
includes, among other things, of course a substance abuse 
benefit. If the plan is reauthorized, the provider network will 
follow because for the first in the State, providers will have 
a reliable source of payment.
    Finally, there's a bill--it was mentioned by Ms. Weber--
mandating the adoption of safe and responsible opioid 
prescribing rules by the professional boards which oversee 
prescribers of opioids, and my office has been a key driver in 
that. And so why is that important? Simply put, we need to stop 
creating new addicts. Overprescribing is a huge problem in our 
country with about 5 percent of the world's population. Some 
way, Americans consume 80 percent of the world's opiates. In 
New Hampshire, the problem is more severe than in many other 
parts of the country as we rank near the top in the amount 
long-acting extended release opioids and high dose pain 
relievers prescribed.
    Overprescribing of prescription opiates had led to our 
heroin problem. According to the CDC, 4 out of 5 heroin addicts 
were first addicted to prescription opiates. In other words, 
the prescription opiates led to the fentanyl and heroin deaths 
I was showing in the slides earlier.
    That's why the CDC has issued draft opioid prescribing 
guidelines, which is supported in a letter co-authored with 
Attorney General Pam Bondi of Florida, which was joined by 34 
other States attorneys general in just 2 business days. So it 
gives you a sense of the depth of the problem nationwide.
    The rules before the legislature adopt many of those 
guidelines and will require a thoughtful approach to 
prescribing opiates, and with that, over time, less patients 
becoming dependent or addicted on opioids. I'm pleased to 
report that that bill recently passed its first hurdle in 
Committee with an 18-0 ought to pass recommendation to the full 
House.
    Thank you for allowing me to provide you with an overview 
of the problem here in New Hampshire. While many of the actions 
being undertaken at the State level will benefit the veteran 
population, more needs to be done I know. As you know, the 
veteran population has been hit especially hard by the 
epidemic, and I applaud the work of your Subcommittee. And 
thank you for you taking the time to come here to New Hampshire 
to hear from myself and the rest of the speakers.
    Thank you, Mr. Chairman.

    [The prepared statement of Joseph Foster appears in the 
Appendix]

    Mr. Coffman. Mr. Foster, thank you so much for your 
testimony.
    Dr. Franklin, you are now recognized for 5 minutes.

               STATEMENT OF JULIE FRANKLIN, M.D.

    Dr. Franklin. Good morning, Chairman Coffman, Ranking 
Member Kuster, and Members of the Committee. Thank you for the 
opportunity to discuss VA's pain management programs and the 
use of medications, such as opioids, to treat veterans 
experiencing acute and chronic pain. I am accompanied today by 
Dr. Grigory Chernyak, chief of anesthesiology and pain service 
at the Manchester VA Medical Center.
    Chronic pain affects a large portion of the veteran 
population with about 50 percent of veterans in VA's health 
care system living with some form of chronic pain. The 
treatment of veterans' pain is often very complex. Many 
veterans have survived severe battlefield injuries resulting in 
lifelong, moderate, to severe pain related to damage to their 
musculoskeletal system and permanent nerve damage, which can 
impact their physical abilities, emotional health, and central 
nervous system.
    Chronic pain management is challenging for veterans, their 
families, and clinicians. VA continues to focus on identifying 
veteran-centric approaches that can be tailored to individual 
needs using medication and other modalities. Opioids are an 
effective treatment for some patient, but they're use requires 
constant vigilance to minimize risks and adverse effects.
    VA launched a system-wide opioid safety initiative in 
October of 2013, and has seen significant improvement regarding 
the use of opioids. Today, 105,000 fewer patients are on long-
term opioid therapy, and the overall dosage of opioids in the 
VA system is decreasing.
    In March 2015, VA launched the new Opioid Therapy Risk 
Report tool, which provides detailed information on the risk 
status of veterans taking opioids. This assists VA primary care 
clinicians with pain management treatment plans. The tool is a 
core component of VA's reinvigorated focus on patient safety 
and effectiveness.
    VA data, as well as peer reviewed medical literature, 
suggests that VA is making progress relative to the rest of the 
Nation. In December 2014, NIDA-sponsored health service 
researcher, Dr. Mark Edlund, and his colleagues published an 
article in the journal Pain. This study of VA pharmacy and 
administrative data looked at VA opioid prescribing practices 
for the treatment of chronic non-cancer pain.
    The study found that approximately 50 percent of veterans 
in this cohort received an opioid as part of treatment. Half of 
these veterans only received them short-term for less than 90 
days per year. The average daily dose in VA is 20 morphine 
equivalents, which is considered modest. VA patients with 
substance use disorder did not receive high-volume opioids at 
increased rates as has been documented in the non-VA 
population.
    The improvements reflected in this study and since signal 
an important downward trend in VA's use of opioids. VA expects 
this trend to remain as it continues its efforts to promote 
safe and effective pain management therapies.
    Manchester VA has established acupuncture and 
interventional pain programs, and is developing a chiropractic 
program. Eventually, these services will be part of their 
functional restorative pain center. Both Manchester and White 
River Junction VAs' have interdisciplinary pain teams. These 
interdisciplinary teams include pharmacists, mental health 
specialists, physiatrists, primary care, and pain specialists. 
The teams discuss challenging cases and, when appropriate, 
invite patients to participate.
    Since 2011, White River Junction Pain Clinic's monthly 
patient visits have increased from an average of 40 patient 
visits per month to over 160. Our availability to see patients 
has increased, and we have added services, including a chronic 
opioid therapy clinic, acupuncture, and chiropractic care.
    Interventional pain procedure volume has increased during 
the same period from 20 per month to over 60. From its May 2014 
opening through December 2015, the Chronic Opioid Therapy 
Clinic saw a significant decrease in the number of veterans 
treated with high dose opioids. Many patients have told us they 
feel much better since they've reduced their medication doses. 
For example, one patient was able to travel to Florida with his 
wife after spending many years homebound.
    In conclusion, VA continues to research pain treatment, 
complementary and integrative medicine, and opioid abuse. VA 
has been at the forefront of pain management techniques, and we 
will continue to innovate to better serve the needs of 
veterans.
    Mr. Chairman, we appreciate this Committee's support and 
encouragement in identifying and resolving challenges as we 
find new ways to care for veterans. We are prepared to respond 
to any questions you may have.

    [The prepared statement of Dr. Julie Franklin appears in 
the Appendix]

    Mr. Coffman. Dr. Franklin, thank you so much for your 
testimony and for all you do for our veterans.
    Walgreens launches a Safe Medication Disposal Program in 39 
States. Dr. Franklin, are you aware of a safe medication 
disposal program or drug takeback program available to veterans 
at the VA?
    Dr. Franklin. Yes. We have, I believe, two different 
methods. The one I could speak most accurately is that patients 
can pick up an envelope, which we will send their medications 
to a centralized repository for disposal.
    Mr. Coffman. The media has reported that only 52 out of 153 
VA medical centers offer alternative therapies to veterans. Dr. 
Franklin or Dr. Chernyak, although both of your facilities do 
seem to offer alternatives, why do you think these therapies 
are not offered at all VA facilities? Who would like to start 
with that?
    Dr. Chernyak. I would like to say to you, Mr. Chairman and 
Ranking Member--
    Mr. Coffman. I do not think your microphone is on. We might 
have to shift microphones there.
    Dr. Franklin. He can use mine.
    Dr. Chernyak. First of all, I would like to thank you, 
Chairman Coffman, and Ranking Member Ms. Kuster, and other 
Members of the Committee to allow me to be here and speak.
    I think one of the problems is that not too many 
specialists are trained in alternative techniques, such as 
acupuncture. The other problem is that as far as I know, VA 
cannot even hire acupuncturists. Acupuncturists are being hired 
as health technicians with pretty low salary. That is why for 
the most they are not really interested to work at the VA.
    And MDs practice acupuncture at the VA, but there are not 
too many MDs who are trained in acupuncture. And chiropractors, 
too, can practice acupuncture at the VA. And, again, there are 
not too many chiropractors who are specialized in acupuncture.
    So VA just recently started chiropractors, as far as I 
know, a few years ago, and the situation has been improving, 
but it is still not as good as we would like it to be.
    Mr. Coffman. I think probably the capacity under the Choice 
Program is probably somewhat limited in terms of utilizing 
practitioners within the community that are not in the VA. 
Okay, that is something that I think the Committee could look 
into.
    Mr. Foster, in your testimony you noted a recent piece of 
State legislation that was passed that requires physicians to 
query or ask the State's prescription drug monitoring program 
in many instances, and it requires prescription data to be 
submitted daily. Do you have any idea or any data on the 
compliance rate with this requirement?
    Mr. Foster. The effective date is that into the future.
    Mr. Coffman. Oh, okay.
    Mr. Foster. I can tell you, though, that registrations, we 
were late to adopt prescription drug monitoring program. I 
think we may have been the 48th or 49th State to do it. It went 
into effect in October of 2014. It required physicians and 
other prescribers to register. We have had very compliance 
around that, so I am hopeful that that is a sense of how people 
will take it when they have to start utilizing it as well.
    I would imagine it is going to be good. I know that there 
is commitment to educate folks around it, and also to make the 
system more user friendly. It is going to be upgraded so it is 
easier to use for physicians.
    Mr. Coffman. Do you, if VA physicians are complying with 
that? I know probably Federal versus State it would probably 
have to be voluntary, but do you know if they are voluntarily 
complying with that?
    Mr. Foster. I do not, and I know there has been a question 
around whether they have to comply.
    Mr. Coffman. Okay. Dr. Franklin--
    Mr. Foster. Dr. Franklin--
    Mr. Coffman [continued].--can you comment on that?
    Dr. Franklin. I can address that question.
    Mr. Coffman. Sure.
    Dr. Franklin. The VA does require annual interrogation of 
State prescription drug monitoring programs.
    Voices. We cannot hear you.
    Mr. Foster. I said the VA does require use of State 
prescription drug monitoring databases, and we have begun to 
measure this in VISN 1 to make sure that we are looking at 
least annually for every patient. Both physicians and 
pharmacists can use the database, and we make a note for the 
patient's chart.
    Mr. Coffman. Okay. But is that reporting just to VA 
authorities, or do you also plan to report to the State?
    Dr. Franklin. I believe that New Hampshire is reporting at 
this time. Vermont was reporting to the State of Vermont, and 
because of a switch of vendor had to stop.
    Mr. Coffman. Okay. Thank you very much.
    Ms. Kuster, you are now recognized for 5 minutes.
    Ms. Kuster. Sure, thank you. Just to follow-up on this, one 
of the issues where New Hampshire is such a small State, and we 
have the border with Vermont and Massachusetts and Maine that 
Mr. Guinta and I are addressing is an interstate prescription 
drug monitoring. And then also, just to note that our Committee 
last week did add an amendment offered by our colleague, Jackie 
Walorski from Indiana, to increase VA compliance with 
prescription drug monitoring. So I think it is definitely a 
critical component.
    And part of what made it slow in New Hampshire is it was a 
voluntary program, and I think it is critically important that 
all physicians and treatment providers participate.
    So I wanted to address my questions to Dr. Franklin and Dr. 
Chernyak, and if you could just describe a little bit more the 
program first at White River and then in Manchester for 
engaging the trends. As it was described to me, it is very 
hands on. It includes drug monitoring. If you could just share 
with our audience, and I want to welcome all who are here. We 
have a number of veterans groups and veteran interest groups. 
We also have civilian providers. And the goal coming out of 
this would be to educate the civilian treatment community on 
the success that you have been having, so if you would share. 
And you will need to speak like right into the mike. Yeah, 
thank you.
    Dr. Franklin. Thank you. Thank you, Congresswoman Kuster. I 
believe you are referring to our Chronic Opioid Therapy 
Treatment Clinic, which it really targets high dose, high-risk 
veterans, so patients receiving greater than 100 morphine 
equivalent daily dose, or patients with significant risk for 
abuse or misuse.
    We take all referrals, of course, and give them a two-hour 
educational program. We then obtain their consent for treatment 
with chronic opioid therapy and a baseline urine drug screen. 
They then have a 90-minute individual with our nurse 
practitioner where she reviews their history, further educates 
them, performs a physical examination, and reviews previous 
laboratory results. The veteran and our nurse practitioner then 
discuss a treatment plan.
    The veterans are followed every 28 days. They come in, 
typically again will leave a urine specimen for evaluation, and 
other treatments are offered. We may wean doses if we feel that 
they are not effective as high doses may actually increase 
pain. Patients often voluntarily reduce their dose when they 
really understand how risky these medications are, and other 
treatments are offered such as acupuncture, chiropractic care, 
et cetera.
    Ms. Kuster. And have you found that you have been able to 
decrease the dosage or decrease the use of opiate medication?
    Dr. Franklin. We have decreased the doses significantly. In 
our highest dose group, those receiving greater than 400 
morphine equivalent daily dose, we have reduced those patients 
by 50 percent since the clinic started.
    Ms. Kuster. So 50 percent is a dramatic decrease.
    Dr. Franklin. It is a dramatic decrease.
    Ms. Kuster. And could you just comment, if you will, and 
even anecdotally just quality of life for people that had been 
essentially debilitated by either chronic pain or the 
combination of chronic pain and opiate medication?
    Dr. Franklin. Yes. Well, for example, we have some patients 
who have become much more functional and are enjoying life 
more. Typically, they describe their pain as similar. 
Occasionally, they have reduced pain as a result of decreasing 
medications that may be causing opioid hyperalgesia. We have 
had some patients who are now on Suboxone as they really were 
suffering from substance use disorder more than pain, and their 
quality of life has also significantly increased.
    Ms. Kuster. Great. Dr. Chernyak, I just have a minute left 
in my time this round, but we will come back to it. But could 
you just add anything from Manchester?
    Dr. Chernyak. Yeah. In Manchester, we recently started 
developing our pain program because it was pretty much 
dysfunctional until recently. And I came on board about 6 
months ago, and I established a pretty robust acupuncture 
program, and I started doing some pain interventional 
treatments. And we recently were able to recruit another 
provider who is a chiropractor with strong emphasis in 
acupuncture. So he used to work in Oklahoma City VA Medical 
Center where I used to work, and I brought him with me 
actually. So now he joined our group.
    And so, we started treating a lot of patients with 
acupuncture, and he started doing some chiropractic 
manipulations as well. And we now are going to add one more 
treatment modality, which is called for by modulation. It is 
like low power laser treatment, which is a pretty powerful tool 
for treating pain and other disorders like chronic pain and 
some other things like non-healing ulcers, for example.
    So we are moving forward, and now we are developing a 
program which would consolidate pretty much all services that 
are taking care of chronic pain patients under one roof. That 
would allow better coordination between services because now 
they are all separated and working under separate service 
lines, such as psychiatry, rehab, surgery, and anesthesiology. 
But we are going to try to solidify them, consolidate them, and 
work under one philosophy, if you will. And that would allow 
much better care for our patients.
    That is our future plans for the nearest future actually. 
We are actually working on this project right now.
    Ms. Kuster. Great. Thank you so much. I yield back, Mr. 
Chair.
    Mr. Coffman. Thank you, Ms. Kuster. Mr. Guinta, you are now 
recognized for 5 minutes.
    Mr. Guinta. Thank you, again, to the panelists for being 
here today. I also want to extend our thanks and appreciation 
to General Rodell for--
    Ms. Kuster. Yes, thank you.
    Mr. Coffman. Yes.
    Mr. Guinta [continued].--the use of the facility. He was 
here in the beginning of the hearing, and I am sure has to 
attend to other duties, but wanted to acknowledge him on the 
record.
    First, I want to talk to Mr. Foster. Thank you for being 
here. I agree with you that the focus here has got to be supply 
and demand, that you have to deal with both. So there is a 
public safety aspect that I think needs to be addressed. If we 
have the time later I want to talk to you about that because I 
think we need to be on the offense, and we need to be very, 
very specific about the tools, particularly whether it is State 
or Federal law that we need to utilize.
    I want to talk to you more about the demand because you had 
talked about a couple of things that the governor's commission 
and the legislature is working. One, you talked about drug 
court funding. I totally support that. That is completely 
necessary in order to deal with this as a tool. But the other 
thing you talked about is doctors have the use of the PDMP.
    Would it surprise you to know that I have spoken with, and 
I agree that they need to utilize that. I have talked to 
doctors as recently from New Hampshire as last week who have 
told me that it is an old system. You are in a hospital, and it 
takes sometimes 45 minutes to access it, and as a result of 
that, cannot get current information about a patient that they 
are treating at that particular moment. So that has been a 
frustration expressed to me. I have talked to the medical 
society about it here in New Hampshire. They concur with that 
opinion.
    So I was asked to bring that up here today and see what 
specifically can be done to expedite the improvement of that 
system.
    Mr. Foster. Thank you for the question. As I mentioned, the 
mandatory use of it was pushed forward, and I should say that 
House Bill 1423 actually requires even more extensive use of 
it, and that effective date is January 1st. And the reason for 
that is an acknowledgment that the system is, I guess I will 
call it, clunky. It is being integrated into EMRs in certain 
hospitals to make it easier to get to, but it does have to be 
upgraded.
    One of the things I did not mention is, there is additional 
funding. Believe it or not, the State until recent legislation 
was passed had a requirement that no State funds be utilized 
for the PDMP, a very New Hampshire notion I suppose. It was 
being funded by grants. They have now changed that, and there 
is some funding coming in. There is also some grants that came 
in from the Federal government, and it is being utilized to 
upgrade the system.
    So I have heard that is a problem. It has to be reasonably 
easy to use. I happen to be married to a physician. I know how 
crazy their day is. It is a dynamic profession with more and 
more demands on it, and it has to be easy to use; otherwise, we 
are not going to see it.
    One of the things I would love to see happen is the State 
of New Jersey has developed actually a mobile app for their 
State PDMP. It would be wonderful if that could be utilized 
nationwide.
    Mr. Guinta. Which is very similar, I mean, I have an app 
that I use for my health care that I can monitor and manage 
exactly from my phone when I need an appointment, what 
different levels I have. I mean, we should be able to use that 
kind of technology for this specific kind of circumstance.
    Do you have a sense of how timely the resources, the funds 
would be available to make the upgrade, and then how quickly 
the upgrade can be made, or is that something you--
    Mr. Foster. Only to a limited degree. The individual who is 
responsible, I have talked to her recently. They are talking to 
the vendor, and my sense is things are on track and that we can 
meet the dates, you know.
    Mr. Guinta. I think that is critical. The reason this is 
important and physicians are saying it is important is they 
want to contribute favorably to knowing when a patient is seen, 
whether it is an emergent situation or on a regular basis, to 
verify if they are doctor shopping--
    Mr. Foster. Absolutely.
    Mr. Guinta [continued].--and how they are getting access. 
That is why physicians are saying to me it is critical that we 
focus on this so they have adequate ability to verify 
information.
    I want to go to Ms. Weber very quickly. Mr. Kelleher 
mentioned 15 to 25 percent of veterans are, and I think he used 
the term ``suffering from substance use disorder.'' So that 
percentage could probably be wider depending on your 
definition. Given your position at the Farnum Center, can you 
give us an idea of those 2,000 people, how many are vets, and 
then subsequently, what are the obstacles that vets are sharing 
with you in terms of access to care here in our State?
    Ms. Weber. That is a good question. Since June of last 
year, we have served 30 servicemembers in our inpatient 
program. That is medical detox and our PHP residential program. 
Some of the unique challenges on an outpatient basis, working 
with Reserve members and servicemembers that need to report for 
drill, is there is concern around what is reported to command.
    If a servicemember is working with one of my staff and they 
are saying that they are struggling either with substance abuse 
or another risk factor with that, not reporting to drill, is 
that going to be reported. So there are concerns, and we have 
partnered with members of the National Guard in making sure 
that that is not a barrier in accessing care, some of that real 
legitimate concern. This is their livelihood.
    The second piece is really being able to support their 
family while they are in treatment. I think there is this 
belief that if you have an active substance use disorder, you 
do not function in life. But these are people that are working. 
They are employed. They are supporting families. They are doing 
the best that they can, and they often have relatively unstable 
housing situations, like the gentleman at the end of the table 
spoke of, where they are not able to leave and invest time in 
themselves to take care of the treatment that they need to 
support recovery.
    Those are a couple of the issues that come to mind.
    Mr. Guinta. Thank you. Yield back.
    Mr. Coffman. Thank you, Mr. Guinta, for your questions and 
for being here today for the people of New Hampshire.
    Recently a VA nurse pled guilty to stealing opioids while 
on duty. What is VA's policy for tracking opioids within the VA 
health care system?
    Dr. Chernyak. I can talk only for anesthesia pain division, 
so I cannot talk for any other departments. But we have a 
machine called Omnicell. In order to check out opioids we need 
to sign in, check out necessary dose for a particular patient, 
and then if you have not used the entire dose, you have to 
waste it with a witness. And both witness and the person who is 
wasting medication has to enter this information into this 
Omnicell machine and specify how much was used.
    Mr. Coffman. I am going to have to ask everybody to speak 
up in the microphone. The acoustics in this room are just a 
little bit challenging, and--
    Dr. Chernyak. I was talking about using Omnicell machine 
where we need to sign in, check out medications and then for 
every particular patient. And then if something left over, we 
need to waste it with a witness. And both witness and the 
provider who used the medication should indicate the dose, 
which was actually delivered and the dose which was wasted. So 
that is how we keep track.
    And pharmacy always checks, and if there is any 
discrepancy, they immediately send us notifications. That is 
the way we do it in our department, anesthesia and pain anyway.
    Mr. Coffman. Dr. Franklin?
    Dr. Franklin. There are both legal and joint commission 
standards related to the tracking and disposal of controlled 
substances. The VA complies with those. Typically when a--
    Mr. Coffman. Speak up just a little bit more, please.
    Dr. Franklin. Typically when a provider, such a nurse or 
physician who has access to these medications becomes addicted, 
it is about 30 days before they are either discovered or 
unfortunately found deceased at work.
    Mr. Coffman. Okay.
    Dr. Franklin. I think that is how these instances typically 
come to light.
    Mr. Coffman. Okay. Dr. Franklin, your testimony references 
10 different programs, working groups, committees, et cetera, 
that were developed to deal with pain management. But what 
successes have these group had? Does VA have proof they are 
working?
    Dr. Franklin. Well, the VA certainly has proof that the use 
of opioids has decreased. Measuring such things that are 
important to veterans as quality and level of function is much 
more difficult and hard to do on an aggregate level. Certainly 
people have stories of veterans who are doing well.
    Mr. Coffman. Okay. Are there hours or how many hours of 
patient care are lost due to these groups? Is that 
quantifiable?
    Dr. Franklin. It is very hard to quantify. Most of the 
groups actually meet over lunch hours and that kind of thing, 
so they do not interfere significantly with patient care.
    Mr. Coffman. Mr. Foster, your office launched an 
investigation into the marketing of pharmaceutical drugs. Can 
you comment on the findings of this investigation?
    Mr. Foster. I wish I could. The pharmaceuticals are 
fighting us in discovery at this point in time, and so we have 
not been able to get full-blown discovery from them as of yet. 
I know a lot of my fellow AGs are launching similar 
investigations.
    I heard yesterday that General Schneiderman from the State 
of New York reached an agreement with NDO. You may have heard 
that in the news last night where they are going to terminate 
improper marketing. Obviously the concern here is that use of 
opioids, I think, between 1999 and 2010 quadrupled in our 
country. There are a fair amount of literature and other 
suggestions that part of that was the marketing of some of 
these opioids.
    The notion was that if your patient had real pain, they 
would not become addicted particularly to the long-acting 
opioids because they were more uniform in the way they 
delivered the medication, and that just does not seem to be 
true at all. It seems completely false.
    Back some years ago, one or more of the opioid companies 
said they would stop mis-marketing. We are trying to determine 
whether that is, in fact, the case. We have some doubt about 
that.
    Mr. Coffman. Okay. Thank you very much, Mr. Foster. Ms. 
Kuster, you are now recognized for 5 minutes.
    Ms. Kuster. Thank you. Thank you, Mr. Chair. Again, 
directing to Dr. Franklin and Dr. Chernyak, one of the concerns 
that I have is reports across the country that some veterans 
with chronic pain who have their opioid prescriptions reduced 
have not been given sufficient support services. So they might 
have had the prescriptions reduced, canceled without notice, or 
not giving them the full range of treatment options, and, thus, 
leading them if they are dependent upon opioids to obtain 
prescription opioids illegally or use heroin.
    How is the VA ensuring that these veterans receive the 
appropriate treatments for chronic pain or opioid dependence? 
And how do you balance for veterans with cancer pain or type of 
pain that they need treatment going forward? How are you 
striking this balance to make sure that they are not becoming 
dependent?
    Dr. Franklin. To start answering the first part of your 
question--
    Ms. Kuster. And can you speak up?
    Dr. Franklin. Yes.
    Ms. Kuster. It is very difficult to hear.
    Dr. Franklin. Sorry. I apologize. I believe that this has 
to be a case-by-case answer. Every patient needs different 
treatment. They are a different point in their disease. They 
have different options available to them.
    I can speak to our VA, and we offer treatment to every 
patient, additional pain treatments. Often, it is not something 
they are interested in at the time when we are seeing them. We 
are able to offer substance use disorder treatment really 
immediately in most cases.
    The chief of the Substance Use Disorder Treatment Program 
at White River Junction will come and meet with us and meet 
with the patient when we are talking about our concern for 
substance use disorder driving their use of opioids.
    It is hard to, you know, make a rule that will affect this 
across the country. But I think hiring good people and making 
sure that they have the time to do the work that they need to 
do is a right step. And if you would remind me of the second 
part of your question.
    Ms. Kuster. Well, I think you have addressed it.
    Dr. Franklin. Okay.
    Ms. Kuster. We will hear from Dr. Chernyak. And then one of 
the things that has been very helpful, and I think Mr. Kelleher 
brought it up as well, is the concept of ongoing professional 
education and medical education on pain management and opioid 
prescribing practices.
    So, Dr. Chernyak, if you have anything to add.
    Dr. Chernyak. Dr. Franklin mentioned that it has to be 
addressed case by case, and I completely agree. I am just going 
to give you one example. Probably this week, we had a patient 
who was expressing some dissatisfaction. He is an opioid 
patient. He had pretty significant injuries to his lumbar spine 
and thoracic spine.
    Mr. Coffman. Please speak up a little bit.
    Dr. Chernyak [continued]. In a significant amount of pain. 
And he has been on high doses of opioids, and attempts to 
reduce the doses or change the opioid regimen was not actually 
welcomed by him because he was very concerned. And he did not 
feel like he was cured well enough.
    So what we did, we invited him for our interdisciplinary 
conference and discussed his case with him. It was like three 
different physicians, providers. We discussed everything with 
him very carefully, and when he left he was in a completely 
different mood. So he felt he was really cared about, that he 
had three different physicians sharing their opinions not only 
between each other, but with him as well. And that actually 
changed his attitude completely.
    So eventually he agreed with our plan of action. He agreed 
to switch from opioid to another to reduce the dose, morphine 
equivalent dose. He agreed to add some other complementary 
options, such as acupuncture and other things. So that is just 
one example how we handle this patient. So we invited him for 
our discussions.
    Ms. Kuster. Great, thank you. My time is almost up, but, 
Mr. Kelleher, and maybe this is something we could discuss 
offline for legislation that we hope to introduce. But you 
mentioned about the grant per diem programs, and I am wondering 
how the VA could do a better job designing the program to best 
treat veterans struggling with opioid use disorder.
    Mr. Kelleher. The Grant and Per Diem Program was authorized 
by Congress quite a while ago. I think it is more than 20 years 
ago.
    Ms. Kuster. Can you speak right into the mike?
    Mr. Kelleher. It predates all of the opioid crisis that we 
are facing now. And, you know, it has a requirement that 
whenever a veteran enters, they must agree to going into a 
sober living environment. And it works better for persons who 
are struggling with alcohol abuse, but as we see people coming 
in with opioid addiction, their ability to truly be able to 
function immediately in a sober living environment is very 
hampered.
    And so, I think on the front end, we could benefit from 
more flexibility to accommodate the opioid addicted population, 
say, having the first 30 days or 45 days be a place that will 
allow a connection and treatment to occur and detox.
    Ms. Kuster. Great. Thank you very much.
    Mr. Kelleher. Thank you.
    Ms. Kuster. Thank you. And thank you all for your 
testimony. I am all set. And thank you, Mr. Chair.
    Mr. Coffman. Mr. Guinta, you are now recognized for 5 
minutes.
    Mr. Guinta. Thank you, Mr. Chairman. I want to follow-up on 
what Ms. Custer was just talking about. So the VASH Program you 
have, there are some restrictions in terms of the resources 
that come from the Federal government to New Hampshire. And I 
have talked to LaBrie House, for example, in Manchester about 
that express concern.
    I think in your original testimony, I do not know if you 
used the term of ``housing first.'' I thought that is what I 
heard. The housing first model gives more flexibility and would 
allow somebody who is using a substance to gain housing first 
then treatment. Is that the kind of flexibility that you are 
suggesting?
    Mr. Kelleher. Yes. Our organization has tried hard to 
implement a housing first approach, which basically provides a 
roof over somebody's head first, and does not place 
requirements on treatment, sobriety, and many other things that 
are barriers, especially for veterans trying to access 
permanent housing.
    Mr. Guinta. And if you can try to speak directly into the 
mike if you can. So I support a housing first model. I did not 
at first, and I had experience with this when I was mayor of 
Manchester. And we saw adopting a housing first model greatly 
impacted the opportunity to help somebody who was an abuser or 
in a substance use circumstance, whether it was a drug or 
alcohol, particularly also because there was a dual diagnosis 
component there with a mental health component. So that is 
something if we could work on trying to provide flexibility 
with HUD, that is something that you would utilize.
    Mr. Kelleher. Yes. We are fully supportive of it, you know. 
Over decades, veterans trying to access housing with barriers, 
really housing first just allows for, just really getting 
somebody in a safe, secure place that they can call home, and 
then worry about how to access all of the treatment and 
whatever else they might need in their life at a later point in 
time.
    Mr. Guinta. All right. Thank you, Mr. Kelleher. Dr. 
Franklin, can you talk to me a little bit about both in New 
Hampshire and Vermont, if you feel that we are providing 
adequate alternative services to pain management relative to 
opioid use.
    Dr. Franklin. It is difficult to assess what does 
``adequate'' mean. We feel based on our limited experience so 
far, that there is a very high demand for alternative services, 
particularly acupuncture. We are as a VISN, so the New England 
region, increasing availability of acupuncture services. 
Whether we will meet the demand is something that we will have 
to see. And yesterday, we had a meeting with the network 
director and talked about how to measure that and how to 
respond if we find access issues.
    Mr. Guinta. Do you get a sense of whether is an 
appreciation now within the physicians at the VA that 
alternatives should be a priority, or is there still an 
expectation that ongoing opiate prescription is going to 
continue, prescribing is going to continue?
    Dr. Franklin. I think what we are looking for is a balanced 
treatment. So for some patients, we think that opioids are 
appropriate long term, and for other patients they are of 
limited or no value. I do not see much resistance among 
clinicians at the VA to engaging other therapies.
    Mr. Guinta. The reason I ask that because back in 2015, 
there was a Center for Complementary and Integrative Health 
report that noted specifically, ``Opioids have not been shown 
to be superior to non-opioid pain relievers for treating 
chronic pain.'' And I think there has been a widely used 
threshold that there is not an alternative, whether it is in 
the VA or outside of the VA. So I think that is an important 
issue to highlight as we try to steer people away from opioid 
use, the supply and demand issue that our attorney general had 
talked about.
    I want to go to the Choice Card because my colleague, 
Congresswoman Kuster, and I have co-sponsored the legislation. 
Mr. Coffman is an advocate of this, of trying to fix the 
challenges within the Choice Card system. I want to make sure 
that a veteran, if they cannot access to whether it is 
chiropractic care, or acupuncture, or any alternative at the 
VA, how can you assist them utilizing the VA Choice Card to go 
somewhere else whether they live on the border of New Hampshire 
and Vermont, or whether they live in the southern part of our 
State, or up north.
    Dr. Franklin. Well, we actually refer to Choice frequently 
for things like acupuncture. It is an ongoing treatment so the 
patient would have to come to White River every week for 
several weeks to get treatment, and we prefer--
    Mr. Guinta. Well, how can we solve that? If, say, you live 
an hour and a half away. You should not have to drive all the 
way to White River. The Choice Card, the point behind it is 
that if you live in Manchester, you should be access care in 
Manchester. If you live in Portsmouth, you should be able, or 
Hanover, or Keene. So that is part of the goal of the 
legislation that we have filed, and this is what I hear from 
veterans. The point of the card was accessibility and localized 
accessibility.
    If you could work with us on trying to figure out how to 
resolve that issue, whether it is technical corrections in the 
law or whether it is administrative at the level of the VA in 
Washington. I would be happy to work with you on that on behalf 
of veterans.
    Dr. Franklin. I would be happy to work with you.
    Mr. Guinta. Okay. Thank you. I see my time has expired, so 
I would yield back.
    Mr. Coffman. Thank you, Mr. Guinta. I want to thank 
everybody for their testimony today. And one thing I just 
confirmed with Ranking Member Kuster that when we go back to 
Washington, we are going to certainly look into this issue 
about veterans being able to access alternative care within the 
Choice Program. When you do not offer a particular service that 
they ought to be accessing in terms of for pain management, are 
there any regulatory impediments for that under the existing 
Choice Program as written. And we will be putting out a joint 
statement with Mr. Guinta as a participant in this hearing also 
on that statement.
    Our thanks to the witnesses. You are now excused.
    Today we have had a chance to hear about alternative 
treatments for chronic pain management, some provided with VA 
and some not provided with the VA. Of those programs provided 
by VA, many are limited to only a few facilities, constricting 
the value that could be provided to our veterans.
    This hearing was necessary to accomplish a number of items, 
to demonstrate that there are alternative treatments available 
for chronic pain management, to discuss VA processes for 
sharing best practices across the country, and to allow VA to 
inform this Subcommittee what it plans to do to improve 
coordination of care for all of our veterans.
    I would like to once again thank all of our witnesses and 
audience members for joining in today's conversation, 
particularly Ranking Member Kuster for bringing me out here 
today.
    Ms. Kuster. I look forward to my trip to Colorado.
    Mr. Coffman. She is quite the champion for the State of New 
Hampshire. And so, there was no option in doing that.
    [Laughter.]
    Mr. Coffman. I ask unanimous consent that all Members have 
5 legislative days to revise and extend their remarks, and 
include extraneous material.
    Mr. Coffman. With that, this hearing is adjourned.

    [Whereupon, at 11:54 a.m., the Subcommittee was adjourned.]


                            A P P E N D I X

                              ----------                              

                  Prepared Statement of Peter Kelleher

    March 4, 2016

    Addressing VA Opioid Prescriptions and Pain Management Practices-
Testimony
    Peter Kelleher-President and CEO, Harbor Homes and the Partnership 
for Successful Living
    Thank you to Congresswoman Kuster and other distinguished Committee 
Members and guests, for this opportunity to address this important 
issue that is plaguing our veterans and their families. In my role on 
the Federal VA Advisory Committee on Homeless Veterans, we have 
discussed a wide range of topics on veteran homelessness and I look 
forward to delving further into this conversation.
    I am here representing Harbor Homes and the Partnership for 
Successful Living, a collaboration of six non-profits in the Greater 
Nashua Area that integrate care on the topics of homelessness, 
behavioral and primary healthcare. We offer over 80 programs and 
operate a federally qualified health center (FQHC) for low income and 
homeless individuals where we often serve veterans who may not qualify 
for VA healthcare. We operate 8 veteran-specific programs: a SSVF 
program, a highly successful HVRP program, 4 GPD programs, a project-
based VASH program, and a robust SAMSHA program.
    As a partnership, we offer a myriad of mental health, substance 
abuse, and dual diagnosis programs, especially out of our Harbor Care 
Health and Wellness FQHC and Keystone Hall, one of the largest 
substance use providers and treatment centers in the state. In our 
clinic, we offer medication-assisted treatment (MAT) and are 
endeavoring to provide a full range of MAT services including 
methadone, under one roof.
    Data is varying, but our agency staff reports that approximately 
45-65% of the active veterans we are serving are suffering from a 
substance use disorder, and that 15-25% of them are specifically 
struggling with opioid abuse. The population of veterans who are 
willing to reflect addiction as a disability upon intake into the 
congressionally mandated Homeless Management Information System, 
frequently cite both alcohol and drug use. For example, in 2014 and 
2015, 99% of the veterans citing substance abuse reported a disability 
with both alcohol and drugs. The majority of the veterans we work with 
prefer to admit to alcohol abuse despite their addiction to other 
substances. Our population frequently represents individuals who have 
not been affiliated with the VA healthcare system and therefore have 
not been prescribed opiates for pain and instead self-medicate with 
whatever is readily available.
    We have and continue to work in tandem with the VA and other 
statewide veteran serving agencies, to combat the substance abuse 
crisis. It is indisputable by all veteran serving stakeholders, that 
access to more treatment options and more lengthy aftercare is critical 
in solving this opioid crisis.
    Please allow me to list three suggestions that should be 
considered:

    1)Broaden the VA healthcare services to serve more veterans,
    2)Approval for VAMCs to provide a full range of medication-assisted 
treatment services such as those provided at the Causeway Center in 
Boston,
    3)Transitional, probationary period of 28 day GPD beds with co-
located outpatient services for veterans with SUD who would not be 
successful in a present day iteration of GPD programs.

    Allow me to share a recent story of a veteran, challenged by his 
substance abuse, who found a path to recovery and independence as a 
result of the veteran services provided by Harbor Homes and fellow 
organizations.
    Our SSVF and HVRP staff began working with a 46 year old veteran 
who was not eligible for VA services. He had been laid off from his job 
and then evicted from his home, rendering him homeless. During the 
``needs'' section of his intake assessment, he disclosed that he was in 
treatment for opioid addiction and was currently taking Suboxone. The 
SSVF and HVRP staff were able to move him into permanent housing with 
some financial assistance and secured him a full time job. He received 
a full benefit package from his employer which came with a very high 
deductible. Because of the major increase in the co-pay cost of his 
Suboxone treatment through private insurance, he could no longer afford 
it and slipped back into using heroin again.
    The veteran was facing eviction from his housing and his job was at 
risk due to his job performance. They then tried to seek assistance 
through SAMSHA but because he had been housed through SSVF, he didn't 
fit their criteria. The SSVF representative knew that Easter Seals had 
launched a new program with Farnum and had 5 beds for veterans and 
within 2 hours he was admitted. He successfully completed the 28 day 
program and today, is maintaining his Suboxone treatment with financial 
assistance through Easter Seals Veterans Count program, is maintaining 
his stable housing and employment.
    This story is a clear illustration of how we can move the dial with 
our veterans in crisis, when we can all rely on each other to reach a 
common goal.
    I know we all agree on the premise that substance misuse among 
veterans can be a result of many interrelated moving parts; struggling 
with opioid drug usage from readjustment challenges back into civilian 
life which often stem from Post-Traumatic Stress Disorder, physical 
injuries, and associated pain management. Although more attention is 
being given to the issue of drug addiction among our veteran 
population, the percentage of veterans who seek help is still 
disturbingly low. In our experience, veterans are more apt to avoid 
mentioning at the point of intake, that they may have a substance 
addiction or that they are currently using, for fear of stigma or 
creating barriers to getting help and housing, especially when they are 
experiencing homelessness.
    In my perspective, to effectuate real change in the lives of the 
veterans we serve, we need to look at housing as a critical form of 
healthcare. By first tending to the veteran's housing, we can create 
one tenable link in the braid that is our involvement in their ultimate 
success. Along with other supportive services, we can increase our 
connection with them and encourage their improved mental and physical 
health, reduce their dependency on substances, and increase their 
earning potential through education and employment support. All of this 
will produce a much higher percentage of those who are able to maintain 
their independence, connect with government and nonprofit services, and 
achieve more successful living.

                                 
                 Prepared Statement of Christine Weber
    Good morning and thank you for the opportunity to speak on such an 
important set of issues. Specifically, I will speak as a provider of 
substance use disorder treatment in New Hampshire, a state where the 
number one public health crisis, active addiction, will require 
diligent and informed collaborative efforts if it is to be managed in a 
meaningful way.
    The program that I direct in Manchester serves over 2,000 people a 
year. I say ``people'' instead of addicts, alcoholics, or other terms 
that can be used to create distance between us here today and them. 
However, amongst the people we serve, there are differences. My staff 
is tasked to specifically screen prospective clients by asking the 
question, ``Have you ever served in the military,'' to inform their 
care. It is critical that treatment providers, first responders, 
emergency departments and treatment liaisons understand how to move 
forward when a man or woman in their care answers ``Yes'' to this 
question.
    Service members present to treatment having struggled to navigate 
when and how to ask for help. If you have heard the difficulties 
servicemembers face in accessing adequate medical/surgical care, 
imagine that struggle, and add limited bed availability or substantial 
substance abuse treatment within the VA system. For those that are able 
to identify that they are in need of help, the highest hurdle next to 
access to care is stigma. Our clients have been in country in the 
Yugoslav region, Kuwait, South America, Desert Storm, Vietnam, 
Operation Iraqi Freedom, Enduring Freedom, New Dawn, various regions of 
Afghanistan and multiple stations throughout the world. None of them 
imagined the values conflicts and isolative nature of addiction would 
lead them to contemplating suicide or treatment for alcohol and drug 
dependence.
    Prescribers must take the responsibility of opiate prescribing very 
seriously. Implementing and enforcing substance use disorder curricula 
for students and licensed practitioners through Continuing Medical 
Education is an important step in ensuring that physicians are exposed 
to the nature of the biology of chemical dependence. It is my hope that 
the VA and other important healthcare institutions provide their 
personnel with ongoing and comprehensive training by American Society 
of Addiction Medicine Board Certified peers and licensed clinicians.
    Physicians have met with NH State Representative Rosenwald to 
discuss recent bill(s) to include NH HB1423 relative to prescribing 
practices as well as the PDMP (Prescription Drug Monitoring Program) in 
New Hampshire. It is concerning as a substance disorder treatment 
provider that these efforts may result in legislation that is embraced 
in language only, without enforcement or oversight by the Board of 
Medicine.
    Prevention efforts, utilization of the Screening/Brief/Intervention 
and Referral process, physician training, and coordinating access to 
substance use disorder treatment facilities via Vets Choice are all 
concrete, actionable steps.
    Regardless of MOS, discharge status, or military service, we are 
seeing an increase population in need of structured, clinical 
intervention and support. Without providers and prescribers taking 
initiative, the mortality rate for this chronic and progressive illness 
will continue to rise.

                                 
                  Prepared Statement of Joseph Foster
    Like many states, the illegal and prescription drug opioid crisis 
is the most pressing public health and public safety challenge facing 
New Hampshire.
    It penetrates every aspect of our society; all socio-economic 
groups; all races; each gender and age groups; and it adversely impacts 
our neighborhoods, our schools, our healthcare system, our courts, our 
prisons, our first responders, our businesses and our highways.
    While prescription opioids and Heroin remain extremely problematic, 
unlawfully manufactured Fentanyl is at the center of the State's 
epidemic.
    I am going to show some slides that illustrate the depth of the 
opioid problem in NH prepared by our state Medical Examiner and our 
Department of Safety.

    Slide 1-Drug Deaths

      In 2000.50 deaths
      In 2015.420 confirmed with 14 still awaiting toxicology.

    Slide 2-Highway Deaths Compared to Overdose Deaths

    Fifteen years ago there were twice as many highway deaths as 
overdose deaths-today, there are 4 times as many overdose deaths as 
highway deaths.

    Slide 3--Deaths by Geography

    Overdose deaths are prevalent in every region of the State.

    Slide 3-Narcan Dosage

    Overdoses-thousands of them occurred statewide. The NH Bureau of 
EMS reported that in 2015, 4,235 doses of Narcan were administered in 
the State.

    Slide 4--Deaths by Age

    Fentanyl and other agents do not discriminate by age. Every age 
group has experienced sharp increases in overdoses, but for the very 
young and very old.

    Slide 5-Heroin and Fentanyl

    Deaths from Heroin and Fentanyl are fairly new. As you can see, a 
decade ago deaths from Heroin were rare-and Fentanyl deaths did not 
occur. That changed and did so with a vengeance.

    Slide 6-2015 Data ---Percentage of Heroin/Fentanyl Deaths and 
Opiates

    Of the 420 confirmed drug deaths, 65% were caused exclusively or 
partially by Fentanyl.

ACTIONS
    So, what are we doing in NH to address this epidemic?
    Very broadly speaking, there are two areas to address this problem: 
on the supply side-mostly a law enforcement function; and on the demand 
side-broadly speaking, a public health and education function.
    We cannot arrest our way out of the problem. We need to reduce 
demand and with that supply will drop. That said addressing both supply 
and demand is critical.
    There are a number of law enforcement initiatives taking place 
within the State and across state lines. The problem does not stop at 
our state borders. Interrupting supply requires cooperation by and 
between our federal, state, county and local law enforcement agencies.
    One such initiative is treating our overdose deaths as crime 
scenes. The goal is to hold those who sold the drugs to the victim 
accountable and to gather information so we can get the ultimate source 
of the drugs and disrupt the supply.
    A lot has happened on the public health side and in many ways is 
more important.
    In November, our Governor called a Special Session of the 
Legislature. The House and Senate convened and passed a bill forming a 
25-member Opioid Task Force made up of Representatives and Senators. 
The Task Force worked aggressively over several weeks and came up with 
a number of legislative proposals.
    Many proposals were recommended by the Governor's Office working 
closely with a group of her Department heads, including my office. This 
has truly been a bi-partisan effort-as it should be.

    Some of the legislation already passed:

      Requires physicians to query the State's Prescription 
Drug-Monitoring Program in many instances; and requires prescription 
data be submitted daily;
      Mandates safe opiate prescribing education for 
prescribers; and
      Placed pain specialists on the Board of Medicine to 
insure expertise when reviewing treatment providers for professional 
misconduct.

    Legislation in process would:

      Expand funding for drug courts.
      Reauthorize the NH Health Protection Plan-our unique form 
of Medicaid expansion. This is key to expanding the State's inadequate 
treatment network. The Plan includes a substance abuse benefit. If the 
Plan is reauthorized, the provider network will follow because, for the 
first time, providers will have a reliable source of payment.
      Mandates adoption of safe and responsible opiate 
prescribing rules by the professional boards which oversee prescribers 
of opioids. My office has been a key driver behind this legislation.

    Why is that important? Overprescribing is a huge problem in this 
country. With about 5% of the world's population, some say Americans 
consume 80% of the world's opiates.
    In NH the problem is more severe than in many other parts of the 
country as we rank near the top in the amount of long acting/extended 
release opioid and high dose pain relievers prescribed.
    Overprescribing of prescription opioids has led to our heroin 
problem. According to the CDC, 4 out of 5 heroin addicts were addicted 
to prescription opiates first. In other words, prescription opiates led 
to the Fentanyl and Heroin deaths I mentioned earlier.
    That is why the CDC has issued draft opiate prescribing guidelines 
which I supported in a letter co-authored with Attorney General Bondi 
of Florida which was joined by 34 other state Attorneys General. The 
rules before the Legislature adopt many of those guidelines and will 
require a thoughtful approach to prescribing opiates and with that, 
over time, less patients becoming dependent or addicted to opioids.
    Thank you for allowing me to provide you an overview of the problem 
here in NH. While many of the actions being undertaken at the state 
level will benefit the veteran population more needs to be done. I know 
the veteran population has been hit especially hard by the epidemic and 
I applaud the work of your Committee and thank you for taking the time 
to come here to NH to hear from myself and the rest of the speakers.

                                 
                Prepared Statement of Dr. Julie Franklin
    Good morning, Chairman Coffman, Ranking Member Kuster, and Members 
of the Subcommittee. Thank you for the opportunity to participate in 
this hearing and to discuss VA's pain management programs and the use 
of medications, particularly opioids, to treat Veterans experiencing 
acute and chronic pain. I am accompanied today by Dr. Grigory Chernyak, 
Chief of Anesthesia and Pain Service, at the Manchester, New Hampshire 
VAMC.

Chronic Pain Across the Nation

    Chronic pain affects the Veteran population, with almost 60 percent 
of returning Veterans from the Middle East and more than 50 percent of 
older Veterans in the VA health care system living with some form of 
chronic pain. The treatment of Veterans' pain is often very complex. 
Many of our Veterans have survived severe battlefield injuries, some 
repeated, resulting in life-long moderate to severe pain related to 
damage to their musculoskeletal system and permanent nerve damage, 
which can impact their physical abilities, emotional health, and 
central nervous system. It is important to note as well that there is 
limited clinical trial data supporting the use of opioids for chronic 
pain \1\ and so VHA is committed to reducing overreliance on opioid 
medicines especially in light of the severe negative consequences many 
patients on opioids risk.
---------------------------------------------------------------------------
    \1\ Chou R, Deyo R, Devine B, Hansen R, Sullivan S, Jarvik JG, 
Blazina I, Dana T, Bougatsos C, Turner J. The Effectiveness and Risks 
of Long-Term Opioid Treatment of Chronic Pain. Evidence Report/
Technology Assessment No. 218. (Prepared by the Pacific Northwest 
Evidence-based Practice Center under Contract No. 290-2012-00014-I.) 
AHRQ Publication No. 14-E005-EF. Rockville, MD: Agency for Healthcare 
Research and Quality; September 2014. Available at https://
www.effectivehealthcare.ahrq.gov/ehc/products/557/1988/chronic-pain-
opioid-treatment-executive-141022.pdf downloaded 2-24-2016.

---------------------------------------------------------------------------
Current VHA Pain Management Collaboration

    To implement effective management of pain, VHA's National Pain 
Program oversees several work groups and a National Pain Management 
Strategy Coordinating Committee representing the VHA offices of 
nursing, pharmacy, mental health, primary care, anesthesia, education, 
integrative health, and physical medicine and rehabilitation. Working 
with the field, these groups develop, review and communicate strong 
pain management practices to VHA clinicians and clinical teams.
    For example, the VHA Pain Leadership Group, consisting of Pain 
Points of Contact for the Veterans Integrated Service Networks (VISNs) 
and facilities, meets monthly with the National Pain Program to discuss 
policy, programs, and clinical issues and disseminate information to 
the field as well as to provide feedback to VACO leadership about these 
programs. Several of these groups are chartered to promote the 
transformation of pain care in VHA at all levels of the Stepped Care 
Model: the Pain Patient Aligned Care Team (PACT) Initiative Tactical 
Advisory Group focuses on primary care issues; the Pain Medicine 
Specialty Team (PMST) Workgroup coordinates and provides standards for 
specialty pain services; the Interdisciplinary Pain Management 
Workgroup focuses on developing Commission on Accreditation of 
Rehabilitation Facilities (CARF) certified tertiary care pain 
management programs for complex patients.
    The Opioid Safety Initiative (OSI) Toolkit Task Force has published 
and promoted 16 evidenced-based documents and presentations to support 
the Academic Detailing model of the OSI. More information on the OSI 
Toolkit can be found at the following link: (http://vaww.va.gov/
PAINMANAGEMENT/index.asp).
    The Department of Defense (DoD)-VA Health Executive Council's Pain 
Management Workgroup (PMWG) oversees joint projects with DoD including 
the two Joint Investment Fund (JIF) projects, the Joint Pain Education 
and Training Project and the Tiered Acupuncture Training Across 
Clinical Settings, and other projects that aim to standardize good pain 
care across DoD and VHA.

Pain Management

    In Manchester, VA offers an Interventional Pain Program, 
Acupuncture Program, Physical and Occupational therapies, and is in the 
process of creating Chiropractic and other Complementary and 
Integrative Medicine programs to meet the needs of Veterans. We closely 
collaborate with VHA pharmacy on opioid prescribing to monitor 
prescribing to our Veterans. We hold Interdisciplinary Pain Team 
meetings weekly to collaborate on the treatment we provide to the 488 
patients currently in our program. The process lends itself to frank 
and open discussions which focus on real time issues and improvements 
to the program. Manchester outcomes include: working as a multimodal 
team to cultivate change with the culture of prescribing. 
Interdisciplinary team prescribers include: Surgical, SPRS (Sensory and 
Physical Rehabilitation Services), Primary Care, Mental Health, 
Pharmacy, QM, Medical, CLC (Long term care, rehabilitation Palliative 
care), and Urgent Care. This Interdisciplinary team has allowed 
Manchester providers to decrease opioid dispensing from FY 2011 to 2014 
by 6 percent.
    Since 2011, our Pain Clinic has seen its monthly patient clinic 
visits increase from an average of 40 visits per month to over 160. We 
have increased our availability to see patients on an ongoing basis and 
have added services for patients including a Chronic Opioid Therapy 
Clinic and acupuncture. Our Interventional Pain Procedures volumes have 
increased during the same time period from 20 procedures per month to 
over 60. We offer evidence-based psychotherapy for chronic pain. White 
River Junction is also the lead site for the VISN 1 Pain Mini Residency 
program. One of the patients treated with acupuncture started driving 
again, as well as taking care of her family after years of disability.
    Since our Chronic Opioid Therapy Clinic opened in May 2014 through 
December 31, 2015, we have seen a 50 percent decrease in the number of 
Veterans treated with the highest doses of opioids (greater than 400 
morphine equivalent daily dose). We have seen a 41 percent decrease in 
the number of patients treated with high dose opioids (greater than 200 
morphine equivalent daily dose) during the same time period. Many of 
our patients have expressed that they are feeling much better since 
reducing their doses of medications.
    Our VISN also takes Pain Management seriously. VISN 1 declared Pain 
Management as one of its five top priorities in 2015. The VISN 
committed to improving opioid safety and increasing access to other 
modes of treating pain. We will have an acupuncture clinic at each 
facility, four Commission on Accreditation of Rehabilitation Facilities 
(CARF)-accredited Pain Rehabilitation programs, and increased access 
to, iRest, and evidence-based psychotherapy for pain as a result of 
this commitment.
    Approximately 4-5 years ago, Dr. Chernyak initiated acupuncture 
services and established an acupuncture clinic at the Oklahoma City 
VAMC. This clinic turned out to be very successful in helping Veterans. 
During this period, many Veterans contacted the administration with 
testimonial letters and with requests to expand this service to make it 
more accessible for Veterans. As a result, the Oklahoma City VAMC hired 
a dedicated Acupuncture specialist, and today this clinic sees 
approximately 50 patient visits per week.
    Acupuncture has been used in the treatment of different kinds of 
acute and chronic pain, chronic headaches, migraines, various addiction 
problems, psychological issues such as PTSD, depression, anxiety, and 
in many other health disorders. This mode of treatment has withstood 
the test of time, as it has successfully survived several thousand 
years of clinical practice in various forms and in many different 
cultures. It is not unusual to see instances when very difficult health 
conditions, especially those resistant to conventional treatment 
modalities, are successfully treated with acupuncture.
    Currently, new, high tech methods of acupuncture point stimulation 
are clinically available, such as the use of low level laser therapy 
(i.e., cold laser therapy). This method allows the clinician to achieve 
an effect without actually penetrating the skin with a needle and, 
without causing the pain sometimes associated with needle insertion. 
Cold laser therapy, or photobiomodulation therapy, is a non-invasive 
treatment modality that we are working to implement in our Integrative 
Pain clinic.
    Both Dr. Chernyak and my goal is to build a robust Integrative Pain 
Center with a strong emphasis on Complementary and Integrative Medicine 
approaches to the treatment of pain at all our facilities. This 
approach would also address the issue of opioid overuse. Usually, 
health care providers tend to refer their patents for Complementary and 
Integrative Medicine therapies for chronic pain issues only after all 
other treatment modalities have failed. Therefore, Complementary and 
Integrative Medicine therapies are often considered as a last resort or 
a therapy of despair. Dr. Chernyak believes that this practice should 
be reversed and that Complementary and Integrative Medicine therapies 
should be offered at a much earlier stage in the treatment process 
along with physical therapy. Complementary and Integrative Medicine 
modalities, to include acupuncture, should be considered before more 
invasive treatment options are sought and most certainly before chronic 
opioid pain management is prescribed. Acupuncture has the added benefit 
of being inexpensive, and in our experience has virtually no side 
effects when performed by properly trained personnel.
    Both Manchester and White River Junction have added positions to 
ensure that we have the expertise to provide interventional pain 
injections or even surgical help. Furthermore, it is our desire that 
both of our facilities will be able to initiate and conduct a number of 
research projects and possibly a pain fellowship program in 
collaboration with one of the teaching institutions.

VA's Progress in Pain Management

    Chronic pain management is challenging for Veterans and clinicians 
- VA continues to focus on identifying Veteran-centric approaches that 
can be tailored to individual needs using medication and other 
modalities. Opioids are an effective treatment, but their use requires 
constant vigilance to minimize risks and adverse effects. VA launched a 
system-wide OSI in October 2013, and has seen significant improvement 
in the use of opioids. The Specialty Care Access Network-Extension for 
Community Healthcare Outcomes (SCAN-ECHO) and the OSI, have been 
designed to integrate into the Academic Detailing model. Academic 
Detailing is a proven method in changing clinicians' behavior when 
addressing a difficult medical problem in a population. Academic 
Detailing combines longitudinal monitoring of clinical practices, 
regular feedback to providers on performance, and education and 
training in safer and more effective pain management.
    Most recently, in March 2015, we launched the new Opioid Therapy 
Risk Report tool which provides detailed information on the risk status 
of Veterans taking opioids to assist VA primary care clinicians with 
pain management treatment plans. This tool is a core component of our 
reinvigorated focus on patient safety and effectiveness.
    VA's own data, as well as the peer-reviewed medical literature, 
suggest that VA is making progress relative to the rest of the Nation. 
In December 2014, an independent study by RTI International health 
services researcher, Mark Edlund, MD, PhD and colleagues, supported by 
a grant from the National Institute of Drug Abuse, was published in the 
journal PAIN \1\. This study, using VHA pharmacy and administrative 
data, reviewed the duration of opioid therapy, the median daily dose of 
opioids, and the use of opioids in Veterans with substance use 
disorders and co-morbid chronic non-cancer pain.
---------------------------------------------------------------------------
    \1\ Edlund MJ et al, Patterns of opioid use for chronic noncancer 
pain in the Veterans Health Administration from 2009 to 2011. PAIN 
155(2014) 2337-2343.

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    Dr. Edlund and his colleagues found that:

      About 50 percent of veteran with chronic non-cancer pain 
in this cohort received an opioid as part of treatment.
      Half of all Veterans receiving opioids for chronic non-
cancer pain, are receiving them short-term (i.e.: for less than 90 days 
per year);
      The daily opioid dose in VA is generally modest, with a 
median of 20 Morphine Equivalent Daily Dose (MEDD),
      And the use of high-volume opioids (in terms of total 
annual dose) is not increased in VA patients with substance use 
disorders as has been found to be the case in non-VA patients.

    Although it is good to have this information, a confirmation of our 
efforts for several years, starting with the ``high alert'' opioid 
initiative in 2008 and multiple educational offerings, by no means is 
VA's work finished. By virtue of VA's central national role in medical 
student education and residency training of primary care physicians and 
providers, VA will be playing a major role in this transformation 
effort. But we have already started with our robust education and 
training programs for primary care, such as SCAN-ECHO, Mini-residency, 
Community of Practice calls, two JIF training programs with DoD, and 
dissemination of the OSI Toolkit.
    A key development is a Joint Incentive Fund DoD-VA project to 
improve Veterans' and Servicemembers' access to Complementary and 
Integrative Medicine, the ``Tiered Acupuncture Training Across Clinical 
Settings'' (ATACS) project. ATACS represents VHA's initiative to make 
evidence-based Complementary and Integrative Medicine therapies widely 
available to our Veterans throughout VHA. A VHA and DoD network of 
medical acupuncturists are being identified and trained in Battlefield 
(auricular) Acupuncture by regional training conferences organized 
jointly by VHA and DoD. The goal of the project is for them to return 
to their facilities and VISNs with the skills to train local providers 
in Battlefield Acupuncture, which has been used successfully in DoD 
front-line clinics around the world. This initiative ultimately aims to 
provide all Veterans with access to this intervention, and a wider 
array of pain management choices generally, when they present with 
chronic pain. Many providers in VISN 1 have received this training 
either through the ATACS program or through the Pain Mini-Residency 
program.

Complementary and Integrative Medicine

    VHA leadership has identified as its number one strategic goal ``to 
provide Veterans personalized, proactive, patient-driven health care.'' 
Integrated Health Care (IH), which includes Complementary and 
Integrative Medicine approaches, provides a framework that aligns with 
personalized, proactive, patient-driven care. There is growing evidence 
for effectiveness of non-pharmacological approaches as part of a 
comprehensive care plan for chronic pain which includes acupuncture, 
massage and spinal manipulation. As I have described, these are all 
being made available to Veterans.
    In 2011, VA's Healthcare Analysis and Information Group published a 
report on Complementary and Integrative Medicine in VA. At that time, 
89 percent of VHA facilities offered some form of Complementary and 
Integrative Medicine however, there was extensive variability regarding 
the degree, level, and spectrum of services being offered in VHA. The 
top reasons for offering Complementary and Integrative Medicine 
included promotion of wellness, patient preferences; and adjunct to 
chronic disease management. The conditions most commonly treated with 
Complementary and Integrative Medicine include: stress management, 
anxiety disorders, PTSD, depression, and back pain.
    VA recognizes the importance and benefits of recreational therapy 
in the rehabilitation of Veterans with disabilities. Currently, over 30 
VA medical centers across the country participate in therapeutic riding 
programs. These programs use equine assisted therapeutic activities to 
promote healing and rehabilitation of Veterans with a variety of 
disabilities and medical conditions (e.g. traumatic brain injury, 
polytrauma). VA facilities participating in such programs utilize their 
local appropriated funds to contract for these services. Facilities may 
also be able to use money in the General Post Fund, a trust fund 
administered by the Department, to pay for these services.
    A monthly IH community of practice conference call provides VHA 
facilities national updates, strong practices, and new developments in 
the field and research findings related to IH.

The Opioid Safety Initiative (OSI)

    The OSI was chartered by the Under Secretary for Health in August 
2012. The OSI was piloted in several VISNs. Based on the results of 
these pilot programs, OSI was implemented nationwide in August 2013. 
The OSI objective is to make the totality of opioid use visible at all 
levels in the organization. It includes key clinical indicators such as 
the number of unique pharmacy patients dispensed an opioid, unique 
patients on long-term opioids who receive a urine drug screen, the 
number of patients receiving an opioid and a benzodiazepine (which puts 
them at a higher risk of adverse events), and the average MEDD of 
opioids. Results of key clinical metrics for VHA measured by the OSI 
from Quarter 4 Fiscal Year 2012 (beginning in July 2012) to Quarter 4 
Fiscal Year 2015 (ending in September 2015) there are:

      125,307 fewer patients receiving opioids (679,376 
patients to 554,069 patients, an 18.44 percent reduction);
      42,141 fewer patients receiving opioids and 
benzodiazepines together (122,633 patients to 80,492 patients, a 34.36 
percent reduction);
      94,507 more patients on opioids that have had a urine 
drug screen to help guide treatment decisions (160,601 patients to 
255,108, a 58.84 percent increase);
      105,543 fewer patients on long-term opioid therapy 
(438,329 to 332,786, a 24.08 percent reduction);
      The overall dosage of opioids is decreasing in the VA 
system as 15,172 fewer patients (59,499 patients to 44,327 patients, a 
25.5percent reduction) are receiving greater than or equal to 100 
Morphine Equivalent Daily Dosing.

    The changes in prescribing and consumption are occurring at a 
modest pace, and the OSI dashboard metrics indicate the overall trends 
are moving in the desired direction. OSI will be implemented in a 
cautious and measured way to give VA time to build the infrastructure 
and processes necessary to allow VA clinicians to incorporate new pain 
management strategies into their treatment approaches. A measured 
process will also give VA patients time to adjust to new treatment 
options and to mitigate any patient dissatisfaction that may accompany 
these changes.
    While these changes may appear to be modest given the size of the 
VA patient population, they signal an important trend in VA's use of 
opioids. VA expects this trend to continue as it renews its efforts to 
promote safe and effective pharmacologic and non-pharmacologic pain 
management therapies. Very effective programs yielding significant 
results have been identified and are being studied as strong practice 
leaders. VA intends to implement safe opioid prescribing training for 
all prescribers in response to the Presidential Memorandum Addressing 
Prescription Drug Abuse and Heroin Use \2\.
---------------------------------------------------------------------------
    \2\ The white House Office of the Press Secretary. October 21, 
2015. Presidential Memorandum Addressing Prescription Drug Abuse and 
Heroin Use-Available at https://www.whitehouse.gov/the-press-office/
2015/10/21/presidential-memorandum-addressing-prescription-drug-abuse-
and-heroin downloaded 2-24-2016

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Conclusion

    In conclusion, VA continues to research pain treatment, 
Complementary and Integrative Medicine and opioid abuse. While we know 
our work to improve pain management programs and the use of medications 
will never truly be finished, VA has been at the forefront in dealing 
with pain management, and we will continue to do so to better serve the 
needs of Veterans.
    Mr. Chairman, we appreciate this Subcommittee's support and 
encouragement in identifying and resolving challenges as we find new 
ways to care for Veterans. My colleague and I are prepared to respond 
to any questions you may have.

                               [all]