[House Hearing, 114 Congress]
[From the U.S. Government Publishing Office]
AMERICA'S HEROIN AND OPIOID ABUSE EPIDEMIC
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HEARING
BEFORE THE
COMMITTEE ON OVERSIGHT
AND GOVERNMENT REFORM
HOUSE OF REPRESENTATIVES
ONE HUNDRED FOURTEENTH CONGRESS
SECOND SESSION
__________
MARCH 22, 2016
__________
Serial No. 114-155
__________
Printed for the use of the Committee on Oversight and Government Reform
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COMMITTEE ON OVERSIGHT AND GOVERNMENT REFORM
JASON CHAFFETZ, Utah, Chairman
JOHN L. MICA, Florida ELIJAH E. CUMMINGS, Maryland,
MICHAEL R. TURNER, Ohio Ranking Minority Member
JOHN J. DUNCAN, Jr., Tennessee CAROLYN B. MALONEY, New York
JIM JORDAN, Ohio ELEANOR HOLMES NORTON, District of
TIM WALBERG, Michigan Columbia
JUSTIN AMASH, Michigan WM. LACY CLAY, Missouri
PAUL A. GOSAR, Arizona STEPHEN F. LYNCH, Massachusetts
SCOTT DesJARLAIS, Tennessee JIM COOPER, Tennessee
TREY GOWDY, South Carolina GERALD E. CONNOLLY, Virginia
BLAKE FARENTHOLD, Texas MATT CARTWRIGHT, Pennsylvania
CYNTHIA M. LUMMIS, Wyoming TAMMY DUCKWORTH, Illinois
THOMAS MASSIE, Kentucky ROBIN L. KELLY, Illinois
MARK MEADOWS, North Carolina BRENDA L. LAWRENCE, Michigan
RON DeSANTIS, Florida TED LIEU, California
MICK MULVANEY, South Carolina BONNIE WATSON COLEMAN, New Jersey
KEN BUCK, Colorado STACEY E. PLASKETT, Virgin Islands
MARK WALKER, North Carolina MARK DeSAULNIER, California
ROD BLUM, Iowa BRENDAN F. BOYLE, Pennsylvania
JODY B. HICE, Georgia PETER WELCH, Vermont
STEVE RUSSELL, Oklahoma MICHELLE LUJAN GRISHAM, New Mexico
EARL L. ``BUDDY'' CARTER, Georgia
GLENN GROTHMAN, Wisconsin
WILL HURD, Texas
GARY J. PALMER, Alabama
Jennifer Hemingway, Staff Director
Andrew Dockham, General Counsel
Michael R. Kiko, Transportation and Public Assets Subcommittee Staff
Director
Ari Wisch, Professional Staff Member
Sharon Casey, Deputy Chief Clerk
David Rapallo, Minority Staff Director
C O N T E N T S
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Page
Hearing held on March 22, 2016................................... 1
WITNESSES
The Hon. Michael Botticelli, Director, Office of National Drug
Control Policy, The White House
Oral Statement............................................... 6
Written Statement............................................ 10
Mr. Lou Milione, Deputy Assistant Administrator for Diversion
Control, Drug Enforcement Administration, U.S. Department of
Justice
Oral Statement............................................... 22
Written Statement............................................ 24
Ms. Kana Enomoto, Principal Deputy Administrator, Substance Abuse
and Mental Health Services Administration, U.S. Department of
Health and Human Services
Oral Statement............................................... 35
Written Statement............................................ 38
Leana S. Wen, M.D., MSC., FAAEM, Health Commissioner, Baltimore
City Health Department
Oral Statement............................................... 48
Written Statement............................................ 50
The Hon. Teresa Jacobs, Mayor of Orange County, Florida
Oral Statement............................................... 101
Written Statement............................................ 104
APPENDIX
March 19, 2016, Baltimore Sun ``The Effects of Opioid
Overprescription Are Evident in the Emergency Room'', submitted
by Mr. Mica.................................................... 152
October 30, 2015,New York Times ``In Heroin Crisis'', submitted
by Mr. Lieu.................................................... 154
October 29, 2010 Time ``Marijuana as a Gateway Drug The Myth That
Will Not Die'', submitted by Mr. Lieu.......................... 158
Response from Mr. Milione, DEA, to Questions for the Record...... 160
Response from Ms. Enomoto SAMHSA to Questions for the Record..... 170
Response from Dr. Wen, Baltimore City Health, to Questions for
the Record..................................................... 182
AMERICA'S HEROIN AND OPIOID ABUSE EPIDEMIC
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Tuesday, March 22, 2016
House of Representatives
Committee on Oversight and Government Reform
Washington, DC
The committee met, pursuant to call, at 10:01 a.m., in Room
2154, Rayburn House Office Building, Hon. John Mica presiding.
Present: Representatives Mica, Turner, Jordan, Walberg,
Amash, Gowdy, Massie, Meadows, DeSantis, Buck, Walker, Blum,
Hice, Carter, Grothman, Hurd, Palmer, Cummings, Maloney,
Norton, Clay, Lynch, Connolly, Cartwright, Lawrence, Lieu,
Watson Coleman, DeSaulnier, Boyle, and Lujan Grisham.
Mr. Mica. Good morning. I would like to welcome everyone
this morning to the Committee on Oversight and Government
Reform, and to a hearing which is entitled ``America's Heroin
and Opioid Abuse Epidemic.'' I would like to welcome our
ranking member, Mr. Cummings, and all the members and our
witnesses this morning to this hearing and call the hearing to
order.
Without objection, the Chair is authorized to declare
recesses at any time.
The order of business this morning will be as follows. We
will begin the hearing with opening statements from myself and
the ranking member. Other members are welcome to submit opening
statements, and with Mr. Cummings' support we will leave the
record open for 5 days, legislative days, for additional
comments or statements.
Without objection, so ordered.
And when we complete the opening statements, we will turn
to our panel of witnesses. We have five distinguished witnesses
today, three at the Federal level, one at the state, and one at
the local level for our hearing. We will swear those witnesses
in, and then we will hear their testimony, and then we will
proceed with questions. So that will be the order of business
that will follow.
So again, welcome, and I will start with my opening
statement.
Unfortunately, the United States is experiencing an
historic epidemic of drug overdose deaths. Today, drug
overdoses are the leading cause of accidental death in the
United States. In 2014--I don't have the 2015 figures yet, but
in 2014 there were--listen to this--47,055 deaths caused by
drug overdose. That means if this hearing lasts for two hours,
10 people will die in the next two hours in the United States
from drug overdose deaths.
This is a little chart showing you the increase since 1999.
I remember I chaired Criminal Justice Drug Policy Oversight
Subcommittee from 1998 to 1999, and we thought we had an
epidemic back in 1999 with 16,000, and I can show you some of
the headlines from my local newspapers where we had many people
dying over a weekend. Unfortunately, that is what we are seeing
again in my community and across the United States.
Unfortunately, more Americans have died from drug-related
overdoses in one year than all that were killed in the lengthy
Korean War. If the current trend continues, the annual death
rate could climb beyond those killed in Vietnam over that
multi-year struggle in one year.
The graph from the Washington Post illustrates the
disturbing rise in drug overdoses between 1999 and 2014. Now,
of the 47,000, more than 10,000 Americans died of heroin-
related overdoses. Heroin use is increasing at a faster rate.
If you want to talk about a war on women and a war on our young
people, the heroin deaths are killing our women at twice the
rate of men and 109 percent more with our youth.
Unfortunately, we have seen, according to the Centers for
Disease Control and Prevention, that again with heroin deaths
among our youth between 18 and 25 in the past decade have
soared and again lead the statistics, the deadly statistics.
Across all demographics, the rate of heroin-related overdose
deaths has increased 286 percent.
While the exact cause of this epidemic is up for debate,
many experts believe the use of other drugs is also a driving
factor. Addiction to other drugs such as prescription
painkillers and marijuana potentially open the door to an
epidemic now destroying families and communities.
Those addicted to other drugs turn to heroin to get a
similar high because it is cheaper and more readily available.
Mexican drug cartels have established heroin trafficking routes
here in the United States and coming across our borders. Now we
see increased supplies in recent years.
I had a chance to talk with my police chiefs and law
enforcement folks in the district, our HIDTA folks, our DEA
folks, and we are seeing an incredible supply, and we will have
some questions about where that is specifically coming from. We
know a lot of it is coming across the Mexican border.
The impact, unfortunately, is felt in communities across
the nation. Just a few weeks ago I met again with all of the
local officials, and we have one of my local officials who we
will hear from in a few minutes, Teresa Jacobs, our county
mayor in Orange County, who has been forced to deal with the
heroin epidemic in Central Florida in her county. In Orange
County alone, and you will hear more about this, we had 475
related heroin bookings in 2013. By the end of 2015, last year,
we had 840. The majority of those arrested were between the age
of 18 and 44.
The Obama Administration, unfortunately, I believe, has
been sending mixed signals about the use of substances such as
marijuana, which is one of the gateway drugs. Talk to anyone
who is in counseling, treatment, rehabilitation, and you will
find out that marijuana is a gateway drug, and many of the
heroin users start there and work their way up the chain of
deadly drugs.
According to the National Institute on Drug Abuse--now
listen to this--more high school seniors are now using
marijuana than cigarettes. A policy that has been adopted,
unfortunately, has consequences. The ``Just Say No'' drug
policy which was championed by the late First Lady, Nancy
Reagan, has turned into a ``Just Say Okay'' policy, and now we
are seeing the consequences.
While improving treatment is a key, enforcement is and must
remain an essential part of combatting the heroin epidemic.
When I talked to the police chief and I saw the numbers in our
locale, I said, well, it looks like you have been able to keep
the lid on some of this, although it is now at epidemic
proportions. And they told me, Mr. Mica, he said this is only
because we now have antidotes that can bring these people back.
The only reason we aren't seeing double or triple the deaths is
because our law enforcement and our first responders can bring
these people back if they can get to them in time.
Not only illegal immigrants are flowing over the Mexican
border but also illegal drugs. We know that is the main source
of the supply of heroin, cocaine, marijuana, and a host of
other deadly narcotics. Stopping deadly drugs from entering the
United States is a Federal responsibility, and we will hear
from some of those officials engaged in that war.
New statistics show Federal drug prosecutions,
unfortunately, are down 6 percent in the last year, 2015. This
comes after a 14 percent drop since the beginning of the Obama
Administration's so-called Smart On Crime initiative.
Our frontline law enforcement officers, if we are going to
save more of these kids and others who are overdosing, they
should be equipped with the resources to prevent and save them
from overdose deaths, not just our emergency medical officers.
The EMS people get there usually after the first responders,
and it may be too late. So this is something else we have
learned from our local task force and law enforcement
officials.
One of the police chiefs in my district informed me that
just within the last month or so, we had one student who had to
be revived from overdosing three times in one week. That is
astounding. What is astounding is he is still alive and we were
able to catch that.
Speaker Ryan announced addressing this current epidemic as
a priority, and the Senate has acted on some legislation. I
believe that this is absolutely critical, that this whole drug
situation, including the heroin epidemic, become a priority for
this Congress.
I look forward to hearing from our witnesses today as we
examine how to protect our communities from this fast-growing
and skyrocketing national epidemic.
I am now pleased to yield to our ranking member, Mr.
Cummings. Mr. Cummings was my ranking member. We together led
the effort from 1998 to 2000. I remember going into Baltimore
with him and conducting hearings there when people were dying
on the streets in huge numbers. But, Mr. Cummings, we are
unfortunately backsliding, and here we are today. But he did a
great job of trying to save people in his community, and he is
now the ranking member of our full committee.
Mr. Cummings?
Mr. Cummings. Thank you very much, Mr. Chairman. I want to
thank you for holding a hearing on America's heroin and opioid
epidemic.
I want to take a moment before I start to extend our
prayers to the people of Brussels, Belgium.
Mr. Mica. I would join you, and I would ask everyone for
just a moment of silence, if we could.
[Moment of silence observed.]
Mr. Mica. Thank you, Mr. Cummings.
Mr. Cummings. Thank you, Mr. Chairman.
Today's hearing is about a national public health
emergency, and we need to treat it like one. People are dying
in Baltimore, Orlando, Salt Lake City, Manchester, and cities
all across our nation. We can no longer ignore this public
health emergency.
The Congress needs to put its money where its mouth is and
actually help, help our states fund treatment programs to stop
this epidemic in its tracks. Drug treatment facilities without
adequate funding are like firemen trying to put out a raging
inferno without enough water. Last week, Leader Pelosi sent a
letter urging Speaker Ryan to schedule a vote on $600 million
in emergency funding to help states address this epidemic
before this recess week.
Our colleague from Connecticut, Representative Courtney,
has already introduced this bill in the House, and Senator
Shaheen has been pressing this legislation in the Senate.
Congress should not leave town until we take emergency action
to increase funding to help states combat this epidemic.
We must also fully fund President Obama's budget request
for $1.1 billion in 2017. This crisis will not end in a day. It
will take our sustained commitment, and every one of us owes it
to our constituents to make that a priority. They want us to
take action, and they want us to take action now.
Let me tell you why Federal funding is so important. In my
home town of Baltimore, I witnessed with my own eyes, in my own
neighborhood, the destruction drug addiction inflicts on our
communities. The first time I ever heard of a drug overdose
death was 55 years ago from heroin, 55 years ago. I didn't
understand it then. It was a young man in our neighborhood who
we looked up to who turned to heroin, named Bey-Bey, and I can
remember being so confused as to what this was all about.
So I have seen vibrant neighborhoods and hard-working
families and communities destroyed. In Baltimore, where many of
the victims were poor and black, this went on for decades. Our
nation treated this issue like a war rather than a public
health emergency. We incarcerated generations rather than
giving them the treatment they needed.
Now, things are changing. Between 2006 and 2013, the number
of first-time heroin users nearly doubled. About 90 percent of
these first-time users were white. This epidemic has become a
runaway train barreling through every family and every
community in its path. It has no respect for barriers. It is
now responsible for the deaths of 78 Americans every single
day, every single day.
Why is this happening? In part, it is a result of doctors
over-prescribing pain medication and drug companies urging them
on so they can make massive profits. I would like to enter into
the record an op-ed by Emily Narciso that appeared in the
Baltimore Sun on March 19th.
Mr. Mica. Without objection, so ordered.
Mr. Cummings. I just want to read just a paragraph from
this article. It says, ``Prescriptions of opioids have been
traditionally limited to cancer pain and comfort measures. But
in the mid-'90s, companies began marketing these pills as a
solution to a new plethora of ailments. In their efforts to
expand the market, producers understated and willfully ignored
the powerfully addictive properties of their drugs. The
promotion of OxyContin by Purdue Pharma was the most aggressive
marketing of a Schedule II drug ever undertaken by a
pharmaceutical company. The Sackler family, which owns
Stanford, Connecticut-based Purdue Pharma, achieved a place on
Forbes' 2015 List of America's Wealthiest Families. The
Sacklers, the richest newcomers to the list, are worth an
estimated $14 billion,'' $14 billion.
Now, going on, as she explains, the United States has only
5 percent of the world's population, but we consume 80 percent
of the world's painkillers. Five percent, ladies and gentlemen,
of the world's population, but 80 percent of the painkillers we
consume.
So, yes, I believe it was unconscionable that our nation
ignored this issue for decades, but now Republicans and
Democrats are starting to work together, and I thank God that
this day has finally come and the stars are starting to align
for meaningful change.
We now have people like Orrin Hatch, Chris Christie, Rob
Portman, Kelly Ayotte, and Mike Pence realizing the severity of
this crisis and supporting more funding to help our cities and
states. They are beginning to realize that this is not an urban
issue, a rural issue, a black issue, an Hispanic issue, or a
white issue. This is an American issue that affects your
sisters, your brothers, your sons, and your daughters.
There is something else we must do. We can no longer allow
drug companies to keep ripping off taxpayers for life-saving
medications. The Chairman mentioned just a moment ago the drug
naloxone and its life-saving effects. Cities all around the
country have recognized the need to equip their first
responders, police officers and public health officials with
naloxone, a drug that can reverse opioid overdoses in a matter
of minutes. But their efforts have been directly undermined by
corporate greed.
As more first responders began using this drug, the company
that makes it, Amphastar, began to increase its prices by
staggering amounts. In May 2014, a 10-dose pack cost the
Baltimore City Health Department roughly $190. Guess what?
Today, it costs more than $400 for the life-saving drug.
Despite repeated efforts by my home state of Maryland, this
company continues to over-charge for this drug. The company
also continues to obstruct congressional oversight by refusing
to produce all of the documents I requested last May, last May,
about their massive price increases.
Mr. Chairman, today's hearing is rightly focused on the
heroin and opioid epidemic, but I hope the committee will turn
next to my request for documents, as well as my request for a
hearing with executives from Amphastar.
With that, let me welcome our esteemed panel of witnesses
today, and I thank you for being here. In particular, I would
like to welcome Dr. Leana Wen, the Baltimore City Health
Commissioner, who has done an outstanding job. She is a true
national leader in developing and carrying out effective
solutions to the opioid crisis. We are very fortunate to have
her heading our health efforts in Baltimore, and we are very
pleased to have her here today.
And with that, Mr. Chairman, I yield back.
Mr. Mica. Thank you, Mr. Cummings.
Again, we will leave the record open for members who came
in late for 5 legislative days if you would like to submit them
at this point in the record.
Mr. Mica. We now want to again welcome our witnesses. Let
me first introduce them, and then we will swear you in.
I am pleased to welcome the Honorable Michael Botticelli,
and he is the Director of Office of National Drug Control
Policy at the White House.
We have Mr. Lou Milione, and he is the Deputy Assistant
Administrator for Diversion Control at DEA, the Federal Drug
Enforcement Administration at the Department of Justice.
And then we have Ms. Kana Enomoto, and she is the Principal
Deputy Administrator of Substance Abuse and Mental Health
Services Administration at the U.S. Department of Health and
Human Services.
And then we have Ms. Leana Wen, and she is the Health
Commissioner for Baltimore City Health Department.
And then I would like to also welcome my requested witness,
the Honorable Teresa Jacobs, Mayor of Orange County, Florida.
Some of you have been before us before, some of you
haven't. We ask you that you limit your statements to
approximately 5 minutes. You will see the little monitor. You
can also request from the Chair additional statements or
information be added to the record. So if you have a statement
and you want to summarize it, you are welcome to do that.
Since this is an oversight and investigations panel of
Congress, I would like you to stand now and be sworn. Can you
raise your right hand?
Do you solemnly swear or affirm that the testimony you are
about to give before this committee and Congress is the whole
truth and nothing but the truth?
[Witnesses sworn.]
Mr. Mica. All of the witnesses have answered in the
affirmative, and we will let the record reflect that.
We will first turn to our ONDCP representative, the
Director of the Office of National Drug Control Policy from the
White House, Mr. Botticelli.
Welcome, and you are recognized.
WITNESS STATEMENTS
STATEMENT OF MICHAEL BOTTICELLI
Mr. Botticelli. Chairman Mica, Ranking Member Cummings, and
members of the committee, thank you for the opportunity to
appear here today to discuss the issues surrounding opioid
drugs, including heroin and illicit fentanyl, in the United
States, as well as our Federal response.
During his State of the Union address, President Obama
specifically mentioned addressing prescription drug and heroin
use as a priority and an opportunity to work with Congress in a
bipartisan manner on this issue that transcends party, income
level, gender, race, and geography.
The Office of National Drug Control Policy produces the
National Drug Control Strategy, which is the Administration's
blueprint for reducing drug use and its consequences. Using our
role as the coordinator of Federal drug control agencies, in
2011 the Administration released a plan to address the sharp
rise in prescription opioid drug misuse that coincided with a
surge in opioid drug prescribing at the beginning of this
century. As this crisis has evolved with an increase in heroin
and fentanyl use and overdose deaths, the Administration
continues to put forward new initiatives to help deal with
emerging issues.
For example, in October the Administration announced a
series of commitments it obtained from state, local, and
private-sector partners, as well as Federal agencies, aimed at
addressing this epidemic.
Opioids are having an unimaginable impact on public health
and safety in communities across the United States. Fifty-seven
people died each day from opioids in 2010, and by 2014 that
figure was up to 78 people. The number of drug overdose deaths
involving synthetic opioids other than methadone, a category
including fentanyl, has more than doubled since 2012.
These overdose rates are harrowing. However, we are making
some progress. Past-month non-medical use of opioids by
Americans 12 and older was significantly lower in 2014 than
during its peak in 2009, and the number of people initiating
the non-medical use of prescription pain relievers in the past
year also decreased significantly during that time.
Unfortunately, this progress has been counteracted by an
increase in the availability and use of heroin. Heroin purity
has been rising while prices have remained low. The heroin
crisis is compounded by the reemergence of illicit fentanyl, a
powerful synthetic opioid that is sometimes added to heroin to
increase its potency or used unsuspectingly on its own. Since
fentanyl is far more potent than heroin, its use increases risk
for overdose death.
While prescription opioid misuse far surpasses heroin use,
and the transition from non-medical prescription opioid use to
heroin occurs at a very low rate, a recent review article
concluded that this transition appears to be a part of the
transition of addiction among those with frequent use or
dependence rather than a response to the reduction and
availability of prescription medications, as some have
speculated.
Graduate medical education programs do not provide a
comprehensive focus on the identification or treatment of
opioid use disorders. A startling evaluation of health care
claims data found that a majority of non-fatal opioid overdose
victims were receiving an opioid from a prescriber, and 91
percent received an opioid prescription again from a prescriber
following their overdose.
In response last year, President Obama issued a
Presidential Memorandum requiring all Federal agencies to
provide training on the appropriate and effective prescribing
of opioid medications to staff who prescribed controlled
substances as part of their Federal duties.
Just last week, the Centers for Disease Control issued
recommendations for primary care clinicians on the prescribing
of opioids to treat chronic pain. The Administration also
obtained commitments by more than 40 provider groups that more
than 500,000 health care providers will complete opioid
prescriber training in the next two years. And the
Administration continues to work with Congress to make
mandatory prescriber education part of their controlled
substance licensure.
The Administration has also focused on several key areas to
reduce and prevent opioid overdoses, including educating the
public about overdose risks and interventions, increasing
third-party and first responder access to the opioid overdose
reversal medication naloxone, promoting Good Samaritan laws,
and connecting overdose victims and persons with an opioid
overdose to treatment.
Yet, there remains in this country a considerable gap that
inhibits many victims of this epidemic from accessing the
treatment they so desperately need. Therefore, the President's
Fiscal Year 2017 budget proposes $1 billion in new funding over
two years to support cooperative agreements with states to
expand access to medication-assisted treatment and to expand
access to substance use treatment providers in areas across the
country most in need of providers.
And just a few days ago, HHS Secretary Burwell announced
$94 million in Affordable Care Act funding to health centers to
expand the delivery of substance use services, with a specific
focus on medication-assisted treatment for opioid use disorders
in underserved populations.
While we appreciate Congress' support, the President's
proposal underscores the need for additional funding to address
this epidemic.
To address the increase in heroin and illicit fentanyl use
and availability, the National Drug Control Strategy focuses on
identifying, disrupting, and dismantling criminal organizations
trafficking opioid drugs, working with the international
community to reduce the cultivation of poppy, and identifying
labs creating synthetic opioids like fentanyl and its analogs.
In addition, last year ONDCP created the National Heroin
Coordination Group, which is a multi-disciplinary team of
subject-matter experts to lead Federal efforts to reduce the
supply of heroin and fentanyl in the United States, and we have
also committed $2.5 million in high-intensity drug trafficking
area programs to develop a heroin response strategy, providing
law enforcement resources to address the heroin threat across
15 states and the District of Columbia.
We have also been actively engaged with the government of
Mexico on efforts to reduce the flow of heroin and fentanyl
into the United States. Earlier this month, I met with Mexican
Attorney General Gomez and other interagency representatives.
We agreed to further collaboration on efforts to disrupt the
production of heroin and fentanyl. This bilateral cooperation
will be mutually beneficial to both our countries.
Members of the committee, we remain committed to working
with our Federal, state, local, tribal, and private-sector
partners to reduce and prevent the health and safety
consequences of non-medical prescription opioid, heroin, and
illicit fentanyl use. Thank you very much.
[Prepared statement of Mr. Botticelli follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Mica. Thank you, and we will withhold questions until
we have heard from everyone.
Let me recognize Mr. Milione and welcome him, our DEA
representative.
STATEMENT OF LOU MILIONE
Mr. Milione. Thank you, Chairman Mica, Ranking Member
Cummings, and distinguished members of the committee.
DEA views the combined prescription opioid and heroin abuse
epidemic as the number-one drug threat facing the country. I
appreciate the opportunity to appear before you today and talk
about what we at the DEA are doing to address that threat.
Prescription opioids are walking users up to heroin's door,
across that threshold, and into heroin's deadly embrace.
Mexican cartels are entrenched in communities throughout our
country, exploiting the prescription opioid abuse epidemic and
flooding the country with high-purity, low-cost heroin. Those
cartels are forming a toxic business relationship with the
violent distribution cells that are slinging that dope in our
communities.
What is the end result? In one year, almost 30,000 of our
fellow Americans died from a prescription opioid or heroin
overdose. As everyone has acknowledged, this is an unimaginable
tragedy.
DEA understands that we need a balanced, holistic approach
to this epidemic. We stand with our interagency partners,
including those represented here today, and embrace prevention,
treatment, and education as critical to our success. However,
enforcement must be a key component of our overall strategy. We
need to investigate and bring to justice not those suffering
from opioid use disorder but those that are exploiting human
frailty for profit.
Our answer to dealing with this drug threat: attack supply,
reduce demand, and power communities, DEA's 360 Strategy. There
are three prongs to the strategy: law enforcement, diversion
control, and community outreach. My comments today focus
primarily on the Office of Diversion Control's role in that
strategy, but we would be more than happy to follow up with
details about Operation Rolling Thunder.
Rolling Thunder is the heroin enforcement prong of the 360
Strategy that is focused on the violent distribution cells that
are pushing heroin in our communities and the Mexican cartels
that are supplying the heroin that is killing so many
Americans.
With 1.6 million DEA registrants, DEA diversion is uniquely
positioned to assist in this fight with enforcement, education,
and engagement. The vast majority of those 1.6 million
registrants are law-abiding citizens. These are our
practitioners, pharmacists, manufacturers and distributors
working in all our communities. We investigate the very small
percentage of those that are operating outside the law but yet
inflict considerable harm on our country: for example,
practitioners not prescribing for a legitimate medical purpose
outside the usual course of professional practice; pharmacists
not performing their corresponding responsibility to ensure
that the prescription is valid; manufacturers and distributors
not upholding the regulatory obligations to prevent diversion.
How do we do that? With our tactical diversion squads, our
diversion groups, and our great Federal, state, and local
counterparts. Our tactical diversion squads are specialized
units made up of agents, diversion investigators, and intel
analysts. We have 69 of them nationally. We are going to add
eight, bringing our number up to 77 within the next six to nine
months.
We are creating two mobile tactical diversion squads that
can deploy where the need is, giving us a fluid enforcement
capability.
We have almost 700 skilled diversion investigators spread
across this country in our diversion groups. Both the tactical
diversion squads and the diversion groups work with their
respective U.S. Attorney's Office to bring criminal and/or
civil charges against those registrants that are operating
outside the law; and, where appropriate, they bring
administrative actions, DEA's Orders to Show Cause or immediate
suspension orders, potentially revoking a registrant's DEA
registration.
As I said earlier, enforcement will be a key part of the
overall strategy, but engaging with that large registrant
community and educating them are just as critical. In the last
two years, DEA diversion has conducted more than 300 events,
providing education and guidance to thousands of DEA
registrants and industry leaders. Since 2011, with our great
partners at the National Association of Boards of Pharmacy, we
have conducted more than 64 pharmacy diversion awareness
conferences in 29 states and have had the privilege of
interacting with almost 10,000 pharmacy employees about the
risks of diversion.
Finally, we will continue engaging with our interagency
partners on important initiatives, including expanding access
to treatment, mandatory prescriber education, and the safe and
responsible disposal of unwanted, unused prescription drugs.
Early in February, a leading national chain pharmacy announced
that they would place drug kiosks in 500 drugstores in 39
states and Washington, D.C. We see that as a very positive step
in the right direction. We look forward to the day when those
secure kiosks are so commonplace throughout our communities
that people can dispose of their unwanted and unused or expired
prescriptions frequently, safely, and conveniently.
DEA will also continue our national take-back initiative
with national events every approximately six months. During our
September 2015 take-back, from 5,202 collection sites we
collected more than 370 tons of unwanted, unused prescription
drugs. Our next national take-back event is April 30th, about
five weeks from now.
For almost 20 years, I have had the privilege of working
with the brave men and women of the DEA, along with our
Federal, state, local, and foreign counterparts, investigating
some of the most entrenched domestic and foreign criminal
organizations threatening our country. This current drug
threat, the subject of this hearing, is unlike anything I have
ever seen.
We at the DEA will do whatever it takes to fight this
epidemic. We will attack supply, we will work to reduce demand,
we will do our best to empower communities.
I thank you for the opportunity to appear before you and
look forward to answering any questions you have.
[Prepared statement of Mr. Milione follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Mica. Thank you, and we will get to questions after all
of our witnesses.
Let me recognize Ms. Enomoto. She is the Deputy
Administrator for the Substance Abuse and Mental Health
Services Administration at the Department of Health and Human
Services.
Welcome, and you are recognized.
STATEMENT OF KANA ENOMOTO
Ms. Enomoto. Thank you. Good morning, Acting Chairman Mica.
Good morning, Ranking Member Cummings and members of the
committee. My name is Kana Enomoto, and I am SAMHSA's Principal
Deputy Administrator, and I am honored to have been delegated
the duties and authorities of the SAMHSA Administrator by
Secretary Burwell.
Many thanks to all of you for your leadership to raise
awareness and catalyze action on the nation's opioid crisis. As
you have noted, this truly is a matter of life or death.
I know prescription drugs, heroin, and illicit fentanyl
have had devastating consequences in many of your districts. I
know this because SAMHSA partners with leaders in your
communities as they implement life-saving programs for
individuals with or at risk for opioid use disorders.
For example, the State of Maryland and the City of
Baltimore are addressing high rates of opioid-related emergency
room visits and utilizing peers to recruit patients into
medication-assisted treatment. In Florida, SAMHSA's
Prescription Drug Monitoring Program Interoperability Grant
helped get critical data to the front lines of the fight to
prevent prescription drug misuse. In Wyoming, we have seen
fantastic progress as the state has implemented our Strategy
Prevention Framework using data and science to focus their
efforts. And at the Odyssey House in Utah, with SAMHSA's help,
it is increasing access to family-based, family-centered
residential treatment for pregnant and parenting women with
substance use disorders. Healthy babies are being born, and
progress is being made.
And while treatment admissions are increasing, overdose
deaths have reached record numbers, and not enough people are
getting treatment. As a nation, we will not stem the rising
tide of this public health crisis if only two out of ten people
with an opioid use disorder have access to the treatment they
need. It wouldn't work for diabetes, it wouldn't work for HIV,
and it will not work for addiction. We must join together to
ensure that every person with an opioid use disorder who seeks
treatment finds an open door.
Toward this end, SAMHSA is proud to support the President's
National Drug Control Strategy and Secretary Burwell's Opioid
Initiative. In HHS, the Secretary's initiative focuses on three
high-impact areas: changing prescribing behavior, increasing
access to naloxone, and expanding the use of medication-
assisted treatment and recovery.
It is simple: to prevent prescription opioid misuse, we
need to reduce the number of pills in people's medicine
cabinets. SAMHSA will encourage the use of CDC's guidelines for
prescribing opioids in order to chart a safer, more effective
course to management of chronic pain.
We know the vast majority of physicians and other
prescribers are dedicated, well-trained professionals committed
to their patients' good health. We must give them the tools
they need to deliver high-quality, safe and effective care.
Since 2007, SAMHSA has provided continuing education to
over 72,000 primary care physicians, dentists, and other health
care professionals. We also reach local communities through
Drug-Free Community Grants we administer together with ONDCP.
These coalitions do yeoman's work to create environments that
promote health and prevent drug use, including the misuse of
prescription drugs, heroin, and illicit fentanyl.
The second aim of the Secretary's initiative is increasing
access to naloxone. As you have noted, naloxone can reverse a
potentially fatal opioid overdose, but it only works if it is
there when you need it. In SAMHSA's Overdose Prevention Course
for Prescribers and Pharmacists, one of the targeted strategies
we promote is co-prescribing of naloxone with opioid
analgesics, particularly for patients with high risk of
overdose. We also let states know that they may use their
SAMHSA block grant funds to purchase and disseminate naloxone,
as well as for training and education on its use, and soon we
will be issuing a funding announcement for states to purchase
naloxone and equip and train first responders. We appreciate
Congress' strong support in this area.
The third area of the Secretary's opioid initiative is
expanding the use of medication-assisted treatment. Research
tells us that medications, along with behavioral therapies and
recovery supports, are important components of an evidence-
based treatment plan. However, resources are limited, and MAT
remains significantly underutilized.
As Director Botticelli noted, the President's Fiscal Year
2017 budget requests $1 billion in new mandatory funding which
would focus on the continuum of prevention, treatment, and
recovery services, expanding the use of MAT, expanding the use
of telehealth, and building the substance abuse treatment
workforce. The initiative also includes, importantly, $30
million in new mandatory funding to evaluate the effectiveness
of medication-assisted treatment programs under different real-
world situations.
On the discretionary side, SAMHSA proposes to maintain and
grow investments made by Congress in 2015 and 2016. We are
providing funding for 23 more states to expand treatment
capacity for MAT, and we are preserving the behavioral health
safety net by maintaining increases to the Substance Abuse
Prevention and Treatment Block Grant.
We have also worked with ONDCP and DOJ to clarify and
enhance the connection between MAT and the criminal justice
system. Drug courts are the most successful criminal justice
response to addiction in our nation's history. This year we
will prioritize treatment that is less susceptible to abuse and
diversion and expand our technical assistance to ensure that
evidence-based practices are fully implemented.
With all this new care, who is there to provide it? We must
ensure that the substance use workforce is sufficient to meet
growing demand. As such, we are requesting $10 million for a
buprenorphine prescribing authority demonstration to test the
safety and effectiveness of expanding buprenorphine prescribing
to nurses and physician assistants, and the Administration has
requested $20 million for our colleagues at the Health
Resources and Services Administration to grow the addictions
workforce via the National Health Service Corps.
Finally, SAMHSA is proposing a new regulation to increase
the patient limit for physicians who have a waiver to prescribe
buprenorphine.
Members of the committee, thank you for convening this
important hearing. I look forward to working with you to ensure
that we are using our investments strategically, responsibly,
and effectively to deliver the greatest possible impact for the
American people.
[Prepared statement of Ms. Enomoto follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Mica. Thank you.
We will now recognize Dr. Wen, who is with the Baltimore
Health Department, the City Health Department.
Welcome, and you are recognized.
STATEMENT OF LEANA S. WEN, M.D., MSC., FAAEM
Dr. Wen. Thank you very much, Chairman Mica and Ranking
Member Cummings, and members of the committee. Thank you for
calling this important hearing. I am here as an emergency
physician who has treated hundreds of patients with opioid
addiction. I am also here as the Health Commissioner in
Baltimore, where I have declared the epidemic to be a public
health emergency.
Last year, Baltimore launched our three-pronged approach to
fight this on the front lines. First, we have to save lives.
That is why we are making the opioid antidote, naloxone,
available to every single resident. In the ER, I have given
naloxone to patients who are about to die and have watched them
revive within seconds. Naloxone should be part of everyone's
medicine cabinet. In 2015, we trained 8,000 people in the city
on how to use it, including our police officers, who within six
months have saved 21 citizens. In October, I issued a blanket
prescription for naloxone to all 620,000 residents of
Baltimore.
But saving a life without connecting to treatment is just
treading water. So our second approach is to increase on-demand
addiction treatment. We believe that treating addiction as a
crime is unscientific, inhumane, and ineffective. So our city's
criminal justice and public health teams have partnered on drug
treatment courts and on a pilot project where individuals
caught with small amounts of drugs will be offered treatment
instead of incarceration.
The science is clear: addiction recovery requires
medication-assisted treatment, psychosocial support, and
wraparound services. Yet nationwide, only 11 percent of
patients with addiction get the treatment that they need.
Imagine if only one in ten cancer patients could get
chemotherapy. Yet my patients come to the ER seeking addiction
treatment, and I tell them that they must wait weeks or months.
I have had patients overdose and die while they are waiting
because we failed to get them help at the time that they asked.
In Baltimore, we have started a 24/7 phone hotline that
includes immediate access to an addiction counselor or social
worker, and a direct connection to make an appointment. Our
phone line was started less than six months ago and already
receives about 1,000 calls per week, including from police
officers and family members asking for resources.
We have ample evidence to show what works for treating
addiction, but we are nowhere near getting everyone treated,
and we are still very limited, especially when it comes to
wraparound services. Take housing. Every year we estimate that
there are 18,000 turnaways for less than 100 recovery beds.
Addiction treatment reduces crime and saves society money. We
should invest in treating today rather than spending it on
incarcerating tomorrow.
Our third approach is to reduce addiction through educating
the public and doctors. We launched a campaign to reduce stigma
and encourage treatment at DontDie.org that also includes bus
and billboard ads and targeted outreach at libraries, churches,
and bars. Dontdie.org now has the first-of-its-kind naloxone
training so that anyone who watches a short 10-minute video can
print out my prescription to get naloxone.
We are also targeting education to physicians. As the
Administrator said, doctors want to do the right thing. We have
to give them the tools to do so. So I have sent best practice
letters to every doctor in Baltimore to set prescribing
guidelines and require the co-prescribing of naloxone with
opioids.
We are also alerting doctors to emerging trends.
Nationwide, one in three fatal overdoses from opioids involves
benzodiazepines like Valium and Xanax, yet physicians routinely
prescribe this dangerous combination together. Last month, I
co-led a petition to the FDA with 40 other city and state
health officials to call for a black-box warning, which is the
FDA's strongest risk communication, on opioids and
benzodiazepines.
There is a lot that Baltimore has done to emerge as a model
of overdose response and addiction recovery, but we need
further support from Congress, including expanding funding for
on-demand treatment and wraparound services like housing and
peer recovery specialists; directly funding local
jurisdictions, those of us on the front lines with highest
need; removing regulatory barriers like the cap on
buprenorphine and IND exclusion; regulating the escalating
price of naloxone; and funding a national stigma reduction
campaign.
The epidemic of opioid addiction is a national public
health emergency, and we know that addiction does not
discriminate. We are all in this together. So I thank you for
calling this hearing and look forward to answering your
questions.
[Prepared statement of Dr. Wen follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Mica. Thank you.
You are not allowed, unfortunately, in these committee
hearings, to express your opinion or your approval or
disapproval. I just have to let the public know that. Only your
representatives can do that.
Please now to welcome and recognize from my district, the
Mayor of Orange County, Florida. Some of you have asked where
that is. Of course, Orlando is the principal city, and we have
our mayor who started a heroin task force when we were hit with
this epidemic.
She is also accompanied by our--but they are not going to
testify. George Ralls, raise your hand, who is our Public
Health Director. David Siegal, who lost a daughter to a drug
overdose and has turned that tragedy into a concerted public
effort. And Karen Diebold Sessions is the former City
Commissioner from my fair city of Winter Park.
So I welcome the guests accompanying our mayor and
recognize Mayor Jacobs. Welcome.
STATEMENT OF TERESA JACOBS
Ms. Jacobs. Thank you, Mr. Chairman. Chairman Mica, Ranking
Member Cummings, members of the committee, thank you for
calling this hearing, and thank you for this opportunity to
discuss a serious threat facing our cities and counties across
the country.
As Mayor of Orange County, Florida, allow me to share a few
statistics. But first, Mr. Chairman, I would like to ask that a
statement from one of our constituents who you just introduced,
Mr. David Siegal, be added to the record. Mr. Siegal is
President of Victoria's Voice Foundation, and he is father of
Victoria Siegal, who died last summer from a drug overdose at
the young age of 18.
Mr. Mica. Without objection, so ordered.
Ms. Jacobs. Thank you.
Many of you know Orange County as the home to Orlando and
12 other municipalities. We have a population of 1.2 million
people. Last year we broke a national record for tourism,
entertaining more than 62 million visitors.
But many of you probably don't know that last year we also
lost 84 lives to heroin overdoses, and probably nobody will
know that that was a 600 percent increase since 2011.
Four years ago, like so many other counties across the
country, we were fighting pill mills. We worked hard. We
adopted tough regulations at a local and state level. We
provided resources to break opiate addiction, and we were
pretty successful.
Today, the front line has moved but the battle is tougher
than ever. Too many prescription drug abusers have found an
inexpensive and often deadly alternative, heroin. Despite
Central Florida's strong economy and our extraordinary quality
of life, heroin has absolutely exploded. Last year,
approximately 2,000 heroin users moved through our county jail.
Many of these arrests, in fact most of them, were not heroin
possession, but they were other related offenses resulting from
the debilitating effect that heroin use has on its users.
Tragically, in 2015 we housed 100 expectant mothers
addicted to opioids and heroin.
Quite frankly, our county jail has become the treatment
center of last resort for so many people. Yet too many people
still don't realize the severe threat that heroin poses not
only to the lives of the addicts but to the fabric of our
community.
For the good of our citizens and our whole community, we
are fighting, and we are fighting hard. Last summer I convened
the Orange County Heroin Task Force, and I asked our Sheriff
Demings to co-chair the effort. We have 22 high-ranking
officials who served on the task force, from our chief judge to
our state attorney, to medical professionals in all of our
hospitals to our superintendent of public schools to
representatives of our three colleges. I commend the effort of
the Orange County Sheriff's Office and the Orlando Police
Department, as well as our Metropolitan Bureau of
Investigation, because since we formed this task force through
collaboration and dedication, they have arrested more than 370
heroin-related incidents just in six months, 370.
Last week our task force concluded its efforts, and it made
37 recommendations. Similar to the comments that you have heard
from my colleagues here, we recommend bond increases for
trafficking, and we recommend media and social media campaigns
warning about the deadly nature of heroin.
Heroin is a serial killer in our community, and so few
people recognize it for that.
Coordinated efforts to avoid fatal overdoses by demanding
access to naloxone. I commend the work of my colleague here,
Dr. Wen. Congratulations. Naloxone, as you have heard, is a
life-saving drug that is used in severe overdose situations;
and also to look for new opportunities to fight addiction by
coupling detox at our jail with addiction treatment programs
using the drug Vivitrol. Vivitrol is a long-acting opioid
antidote.
In addition to moving forward with the implementation of
these recommendations, we are working with our partners at the
National Association of Counties, which has teamed up
nationally with the National League of Cities. We are working
with HIDTA, and we are working with other organizations to
implement the best practices.
We know there is no single solution, but there are some
universal effective approaches. Enforcement is absolutely
critical to combatting heroin use. In keeping with what we
learned with pill mills, we must be tireless in educating
people that addiction is an illness. It is an illness that
requires serious medical treatment.
From law enforcement to families, the life-saving drug
naloxone needs to be more accessible without a prescription and
available at a reasonable cost.
And one final point. I want you to know that in Orange
County, through our collaborative effort, we are committed to
doing everything we can with the resources that we have. Here
is where we need your help.
Help stop the influx of drugs across the border. We need
you to continue to expand your efforts to stop these deadly
drugs before they enter our communities. Local treatment and
law enforcement will do their part, but the Federal Government
must do everything possible to keep this plague from our shores
and our communities.
Help us treat more addicts. With a regional population of
2.5 million, we have only 26 beds for the uninsured, 26 beds,
and yet 62 percent of the overdoses in our community are among
the uninsured.
And help us raise awareness so that more people will choose
not to try this deadly drug in the first place.
To end this crisis and to save lives, we all need to be
engaged.
I thank you for your attention to this critical issue, I
thank you for your leadership, and I thank you for your service
to our country.
[Prepared statement of Ms. Jacobs follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Mica. I thank you, Mayor Jacobs, for participating
today, and all of our witnesses.
Now we will turn to questions, and I will lead off.
The scope of the problem that we are facing, I don't think
people are comprehending this. From 16,000, when we chaired the
Criminal Justice Policy Subcommittee, 16,000 to 47,000. We are
approaching 50,000 in one year. Heroin is only 20 percent of
that, 10,000 deaths. When are the 2015 figures coming out?
Mr. Botticelli. We hope to have the 2015 figures by the end
of the year. But part of what ----
Mr. Mica. By the end of the year. We can't get them until
the end of the year?
Mr. Botticelli. Well, unfortunately, a part of the issue is
that these data get reported from county ----
Mr. Mica. And 47,000 from 2014, and I am afraid it is going
to be off the charts. That does not count, folks, that does not
count--there are 35,000 automobile deaths in the United States.
Half of those, people have some kind of substance in their
system when they are killing themselves. It used to be that
teens, the biggest killer of teens was automobile accidents.
Now it is drugs. Isn't that right?
Mr. Botticelli. That is correct.
Mr. Mica. Yes. It is killing our youth. We haven't even
gotten into firearms. Firearms are the tool of the drug trade,
and they have illegal weapons that they are using to commit
robberies, mayhem. Again, it is an astounding number. We
haven't killed this many in multiple-year wars as we are
killing in one year.
We will lose, guys, a half-a-million people in a decade at
the rate we are going, or more. Every family has been affected
by it, and now it is just a slaughter out of control.
Now, we have lots of responsibility, and I am all for
treatment. Treatment is at the end of the process. They have
already been addicted. We have got to stop this stuff at our
borders.
I sat with our police chief. I sat with our HIDTA people.
We put in place the HIDTA. I had to do that by legislation a
number of years ago because they play political games with even
the creation of high-intensity drug traffic areas, but we did
it years ago. And here we are back where we--we are far beyond
where we ever were then.
This is out of our newspaper from just a few days ago, six
pounds of heroin at OIA. They are bringing this deadly, these
deadly substances, and it is not just heroin.
Mexico, you talked about Mexico, and I said it is not just
illegals coming across the border, but they are coming across
with drugs. Isn't that right, Mr. Milione?
Mr. Milione. Yes, that is correct.
Mr. Mica. I sat with the HIDTA folks and saw the pattern.
These are cartels. They are organized.
What I just heard--did you all see what's his name, El
Chapo? He said he came across the border, it was like a sieve.
That was the major drug dealer, the most sought-after drug
dealer, and he transits the border like it is some kind of a
holiday visit to the United States. So somehow we have to get a
handle on this.
I just looked up the prosecutions. The prosecutions, when
we looked at trafficking with illegal weapons, is down, and
prosecution--I talked to some of my DEA folks; they won't tell
you this on the record. They are not going to say this, but it
is very hard to make cases on these guys. A lot of cases are
dropped on the traffickers. These are dealers in death.
You are aware, sir, that we have prosecutions. You build
the case, you give them to the district, and I am going to
demand a meeting with my U.S. Attorney in the central district
and see why the prosecutions are down, but they are down. Did
you know that?
Mr. Milione. I have seen that they are down. However, I
have also seen that sentences have gone up, and I have seen
that we are focused on the ----
Mr. Mica. But they are telling me it is hard sometimes to
make a case. These are murderers, and we can't stop them. They
are bringing deadly substances in, and the trafficking pattern,
too, trying to find out--some is coming through the U.S. mail.
I will say they told me the mail is starting to crack down. It
gets across the border, and then they transit it in the United
States like they are sending some kind of a gift package. Is
that correct, sir?
Mr. Milione. There are many ways that it comes across into
----
Mr. Mica. Through packaging services? Who are also intent
on getting the package there on time, have to get the deadly
drugs there on time.
So we have to look at every avenue. These guys are using
the border. I was in Mexico years ago. I don't know if you came
with me on that trip, Mr. Cummings, but we warned them.
Now, you can do a DEA signature of heroin and cocaine,
can't you?
Mr. Milione. Yes.
Mr. Mica. And you have looked at the stuff coming across.
Where is it coming from?
Mr. Milione. Mexico.
Mr. Mica. And 15 years ago it was all Colombia, wasn't it?
Mr. Milione. It still comes from Colombia ----
Mr. Mica. But there was very little. I forget, it was black
heroin or something, coming out of Mexico. But Mexico was like
the amateur hour in this game. Now they have become the pros,
and they are dumping this stuff in our communities. By the time
we get to treatment, it is way too late, and it is kind of sad.
I mean, I am all for the naloxone and having that with our
first responders, where it should be. But I told you the story
one police chief told me, three times in one week a student,
they had to revive him.
We have to change our prescription drugs in the cabinet to
naloxone so people are reviving their surviving kids and
family.
Where is the chart? Now, we have done a good job. Put the
chart up on heroin versus--okay. Look at the opioid drugs at
the top, and heroin. We have actually brought that down a
little bit when it went up. So we have been somewhat effective
on cracking down on prescription drugs. But look at what is
happening with heroin; it is off the charts. It is being
replaced by a cheaper and more available drug.
They told me, sir, and you verify this from DEA, they said
the price is down.
Mr. Milione. That is correct.
Mr. Mica. Yes, it is down. When is the price down when the
supply is all over the place?
So it is not just Baltimore. It is not Washington, D.C. It
is not Orange County. It is New Hampshire, Kentucky, every
state in the United States we are seeing this. Aren't we, sir?
Mr. Milione. That is correct.
Mr. Mica. Yes. So again, I get a little hot to trot over
this, but our job is protecting the citizens of the United
States, primarily national defense. We saw what happened with a
terrorist attack in Brussels. We are being attacked in our
streets, in our schools, in our families.
I mean, again, they killed today 40 people. They killed
50,000 people in the latest statistics we have, which are more
than a year old. I know tough enforcement works. It worked with
Mayor Giuliani in New York. They stopped a lot of the crime,
the drugs, with zero tolerance. Now we have Just Say Maybe, and
I just announced the new Federal policy, Just Say Okay instead
of Just Say No.
Doesn't it have to start, ONDCP Director, with families and
communities?
Mr. Botticelli. I would agree that part of our strategy is
to focus on primary prevention, that we know that by delaying
when people use, particularly kids use alcohol, marijuana or
tobacco, we substantially increase the fact that they are going
to have a life free of drug ----
Mr. Mica. And were you aware that high school seniors now
abuse marijuana more than cigarettes?
Mr. Botticelli. Yes, I have ----
Mr. Mica. That is great commentary on our success in
combatting this with our youth.
I would like to yield now to Mr. Clay.
Mr. Clay. Thank you, Mr. Chair. And thank you and the
ranking member for your comments on the heroin and opioid
epidemic.
Let me start with Dr. Wen, and I want to commend you for
the groundbreaking work that you are doing in Baltimore. You
are not just talking the talk when it comes to speaking out
about ending the stigma related to addiction, you are walking
the walk when it comes to expanding access to treatment for
your residents.
In your testimony, you discuss your efforts to provide
treatment on-demand on a 24/7 basis for Baltimore residents. I
would imagine that ensuring someone can access treatment as
soon as they present themselves as willing to do so is a
powerful tool for making sure that they actually begin
treatment, and that your approach will save hundreds or
thousands of lives as a result.
Today, one of the barriers to treatment is the Medicaid IMD
exclusion which prohibits Medicaid from paying for community-
based, non-hospital inpatient residential treatment in a
facility of 60 or more beds. Unfortunately, the IMD exclusion
means that if you are on Medicaid, you are treated like a
second-class citizen, unable to access what may be the
appropriate care for your substance use disorder.
For the residents you are responsible for in Baltimore, do
you agree that they should have access to the medically
appropriate care they need whether or not they are on Medicaid?
Dr. Wen. Thank you, Congressman Clay. I absolutely agree,
and I thank you for acknowledging that addiction is a disease.
If a patient came to the hospital with a heart attack, we would
never say wait three weeks and maybe if there is a bed
available we will get you in then. The same thing should apply,
and the IMD exclusion is not based on evidence. We desperately
need residential substance use disorder treatments, and
removing the waiver on the Federal level will allow us to
increase the ability to treat all of our patients regardless of
their insurance status.
Mr. Clay. And that would put those patients on equal
footing with everyone else so that we don't seem to be
discriminating based on level of care.
Dr. Wen. Yes, and it would also increase more providers
whom we desperately need at the time, when our treatment
capacity is just 1 in 10 nationwide.
Mr. Clay. Yes, and let me thank you for appearing here
today.
Every city and county, Mayor Jacobs, should have a health
commissioner raising the alarm as forcefully and as effectively
as Dr. Wen is, and hopefully Orange County has that, and
Congress will finally heed the call and do something
significant about the opioid epidemic because it seems as
though we as a country have come together and have decided this
is a national emergency. We should sit up and pay attention. So
let me thank you, too, Mayor Jacobs, for being here and for
what you have done to raise the level of awareness in your
community.
Let me go to Ms. Enomoto. You testified about the work that
SAMHSA does. Can you describe that work in additional detail?
You testified that of the $1 billion in mandatory funding,
SAMHSA proposes $920 million over two years to support
cooperative agreements with states to expand access to
treatment for opioid use disorders. Why is it important that
SAMHSA receive these funds?
Ms. Enomoto. As you have so articulately stated, the need
far exceeds the capacity of our treatment system today, and we
believe that every person who has an opioid use disorder who
seeks treatment, just as Dr. Wen has done, 24-hour access to
treatment, that should be the standard of care for everyone.
With this President's proposal for $920 million to be infused
across two years, we think that would super-charge the capacity
of our states, of our communities with the greatest need so
that individuals who are seeking treatment would have an open
door window when they are ready to get that treatment, because,
as we know, the window can be small for some people, and we
need to take advantage of that opportunity when they come
knocking.
Mr. Clay. Thank you so much for your response.
Mr. Chairman, I yield back.
Mr. Mica. I thank the gentleman.
Let me recognize Mr. Turner from Ohio.
Mr. Turner. Mr. Chairman, thank you for holding this
hearing. Mr. Cummings, thank you for your comments. This is
certainly a scourge that is affecting everyone.
In my community, I was touring a brand-new hospital,
Medical Hospital, and was taken back to a conference room to
meet with the leadership of the brand-new hospital and asked
them what is their most significant challenge, and they told me
babies being born addicted to opiates. A brand-new hospital.
Out of all the Federal regulations, of all the funding issues
that they would have, you would not have thought that the
biggest challenge a brand-new hospital was having was babies
addicted to opiates.
Mr. Botticelli, thank you for all of your efforts. I
appreciate your leadership. I think you are doing a great job
and appreciate your advice to Congress as to how we might be
able to formulate our to-do list.
Mayor, I am a former mayor. Thank you. You live in your to-
do list, so thank you for your representation of the community.
Ms. Enomoto, I would like to put up a few slides that come
from your Fiscal Year 2017 congressional budget justification,
the first one being a quote that says that approximately 1
million Americans need but do not access treatment for an
opioid abuse disorder. Again, these slides come from your
Fiscal Year 2017 congressional budget justification.
Ms. Enomoto, when we hold these hearings, we don't do them
just merely for increased community awareness. We do them for a
congressional to-do list, but also for an agency to-do list. So
that is why I am turning to your budget justification. We know
1 million Americans need but do not access treatment.
The next slide.
For example, more than 80 percent of state prisoners, 72
percent of Federal prisoners, and 82 percent of jail inmates
meet the criteria for having either a mental health or
substance abuse issue. Those are staggering numbers, 80 percent
of state prisoners, 72 percent of Federal, 82 percent of jail
inmates, a mental or substance use issue.
The next slide.
Studies show--again, your budget justification, Ms.
Enomoto. Studies show that only 8.3 percent of individuals
involved with the criminal justice system who are in need of
substance use disorder treatment receive it as part of their
justice system supervision.
Ms. Enomoto, after I left that hospital, I then began the
quest of trying to find out in my community where are the
resources, how can we find resources to provide treatment. In
our criminal justice system, in our community, I was introduced
to people who were struggling to try to provide treatment to
those who are incarcerated, and then I was introduced to a
prohibition in your agency's funding that prevents it from
being utilized for those people who are incarcerated.
So in your very agency's documents, it indicates that the
problem--we have a self-sorting, right? We have people who
present themselves in the criminal justice system with this
problem. We have an understanding that without treatment, they
will not be able to transition and we will, as our chairman has
said, once again be providing assistance to them in either an
overdose situation or see them again in the criminal justice
system. And yet in your funding, there is an exclusion that
prevents communities from using dollars that they receive from
you to actually address that for people who are incarcerated.
To Mr. Clay's comments, in Medicare and Medicaid, there are
also similar exclusions that prevent people who are entitled to
receive their treatment from receiving that treatment.
I have a bill, H.R. 4076, that would eliminate those
restrictions, that would say this is funding that is already
there, it is not an increase in funding, although I am for
increasing the funding, but these are funds that are already
there that would just allow those people to receive it.
Now, Ms. Enomoto, your agency, by rule, could eliminate
that restriction. Why don't you?
Ms. Enomoto. You know, I think the issue that you have
pointed out is clearly so important to communities all across
the country. We know that people in our jails, in our prisons
are over-represented with mental illnesses and substance use
disorders, and getting them adequate care is absolutely
important for this nation.
At the same time, we strongly support approaches such as
drug courts, diversion, early diversion, as well as reentry
programs, and we have made significant investments to ensure
that evidence-based ----
Mr. Turner. Ms. Enomoto, I appreciate all that. But before
I completely lose my time, could you please tell me why your
agency won't waive the requirement and allow your funding to be
able to be utilized for those who are incarcerated who need it
most?
Ms. Enomoto. You know, I want to make sure that I get you
an accurate answer to that, so I am happy to follow up further
either for the record or in person.
Mr. Turner. Excellent, and I do appreciate your hard work.
I know you are trying to assist us also, and I would encourage
members to please co-sponsor 4076, because it would help the
agency have the momentum to waive the prohibition themselves.
Thank you.
Mr. Mica. Thank you, Mr. Turner.
I now recognize our ranking member, Mr. Cummings.
Mr. Cummings. Thank you very much, Mr. Chairman.
Dr. Wen, again, I want to thank you for being here. At the
beginning of today's hearing we put into the record an op-ed
from the Baltimore Sun. ``The Effects of Opioid Over-
Prescription Are Evident in the Emergency Room'' it is
entitled. The author explains that one reason we are now seeing
such a huge increase in heroin overdoses is because legal
prescription painkillers are being over-prescribed. She says,
and I quote, ``Once a patient is hooked, he or she often turns
to street drugs, which can be easier and less expensive to
acquire.'' I think you and just about everybody else has said
that this morning.
I want to be clear: I am not trying to blame the doctors.
They have a very difficult job. But, Dr. Wen, do you agree that
one reason we are seeing an uptick in heroin overdoses is
because of the abuse of prescription opioids? Yes or no?
Dr. Wen. Yes.
Mr. Cummings. The op-ed has a startling stat. It says, and
I quote, ``With only 5 percent of the world's population, we
are consuming over 80 percent of the world's painkillers.'' The
op-ed explains that drug companies are actively promoting this
problem. It says, and I quote, ``Prescriptions for opioids have
been traditionally limited to cancer pain and comfort measures,
but in the mid-'90s drug companies began marketing these pills
as the solution to a new plethora of ailments. In their efforts
to expand the market, producers understated and willfully
ignored the powerful addictive properties of their drugs.''
Now, that sounds like drug companies are almost like drug
pushers. The op-ed cites several examples. For instance, it
says this, and I quote, ``The promotion of OxyContin by Purdue
Pharma was the most aggressive marketing of a Schedule II drug
ever undertaken by a pharmaceutical company.''
Dr. Wen, this is big business. How in the world do we
combat this massive and aggressive effort by drug companies
when they are making billions? Go ahead, I am listening.
Dr. Wen. Congressman Cummings, thank you for asking that
question. I appreciate your saying that doctors want to do the
right thing. We want to do the right thing. And actually, when
we talk to our communities, our youth also recognize--if you
ask our youth in schools is heroin good or bad, they are going
to say that heroin is bad. But we have a culture of excess. We
have, because of the aggressive marketing of drug companies, we
have this expectation that there should be a pill prescribed
for every pain. This is what we have to change.
So we have to make sure that doctors get the resources, the
tools that they need, including prescription drug monitoring
programs, including guidelines that can help with safe
prescribing. But also we need the resources when we are in the
ER. We need the resources to connect our patients to treatment,
because otherwise we also feel frustrated knowing that our
patients need care but we can't deliver it to them.
Mr. Cummings. Now, you talked about some guidance you sent
out. Does that guidance also include using painkillers that are
not so addictive or not addictive at all?
Dr. Wen. Yes. Our guidelines include three things. The
first is the necessity of co-prescribing naloxone with any
opioids, because somebody could die from this, so they should
get that as well. The second is to be careful about the opioid
medications knowing that they are not first-line medications.
They should only be prescribed for severe pain. And the third
is for the danger of benzodiazepines, which are also killing
our residents.
Mr. Cummings. So the op-ed goes on to explain why drug
companies are doing this, and that is no surprise. It is about
profit. It says, ``The Sackler family, which owns Purdue
Pharma, achieved a place on the Forbes 2015 list of America's
Wealthiest Families. The Sacklers, the richest newcomers to the
list, are worth an estimated $14 billion.'' That is appalling.
I call that blood money, because people are dying big-time.
I want to go back to something, Ms. Enomoto, and maybe some
of you others can answer this. Yesterday I was talking to a
reporter and he was saying that, Cummings, aren't you concerned
that with even more money being requested for treatment and to
deal with this problem, because there are so many more people
getting into opioids and heroin, that money will be spread so
thin that it will not have the kind of impact that you are
hoping for?
Mr. Botticelli?
Mr. Botticelli. To your point, I think we have to have a
comprehensive response to this. First and foremost, we need to
rein in prescribing behavior in the United States. The Centers
for Disease Control just put out recommendations last week that
closely follow the guidance that Dr. Wen put out, because that
is where we know the significant driver is to the problem.
But we also know that despite all of our efforts, we still
have too many people overdosing and dying, largely because they
can't access treatment programs when they need treatment
programs, and this is why the President has put forward a
significant proposal to expand treatment capacity in the United
States.
I hear this wherever I go. I just did a town hall forum in
Toledo, Ohio where the sheriff--I asked the sheriff what one
single thing the Federal Government should be doing to address
this opioid epidemic, and he didn't say we need more police
officers. He said we need more treatment capacity because we
are arresting too many people who haven't been able to access
treatment.
So we took a careful look at how many people need treatment
and tried to adjust the proposal to really focus on making sure
that as many people as possible had access to treatment when
they needed it.
Mr. Cummings. Just one more question. Dr. Wen, what
happened? In other words, this was not a problem before, not as
much of a problem, but then something happened. Can you tell me
what happened? I mean, the numbers that the Chairman cited--and
I realize that people are moving from the opioids to the
heroin, but what happened with regard to the opioids to get so
many people on them, and then for them to move to the heroin?
Do you know?
Dr. Wen. My understanding is that there was aggressive
marketing by drug companies, so that the pain scale is
something that is asked of every patient all the time in the
course of their hospital stay, but the goal should not be
getting to pain free. The goal should be appropriate treatment,
yet this is the expectation that is placed on patients and on
doctors. So doctors are put in a hard place, too, of satisfying
those requirements when all of that was done for drug
companies' benefit.
Mr. Cummings. So doctors have a tough time. In other words,
the patient keeps coming in, and the pain could be at a 2,
being the mildest. The patient has a 2, and then he or she
comes in and doesn't tell the truth and says I am at a 9. Is
that the kind of thing that happens?
Dr. Wen. That definitely happens, and then doctors feel
that they have to get the patient's pain to zero, which
includes over-prescribing of narcotic painkillers in order to
do so.
Mr. Cummings. Wow.
Mr. Botticelli, it seems like you wanted to say something.
Mr. Botticelli. Yes. It seems like we set up an expectation
whereby opioids are the first-line defense around pain
therapies, and I think what we are trying to do through the
guidance and through Dr. Wen is, particularly for people with
chronic pain, that opioids are not the first-line defense to
really substantially reduce pain and we have to focus on
other--and the evidence seems to be pretty strong that people
who are in chronic pain don't have significantly better
functioning when they are on opioids, that we need to be
thinking about things like exercise and diet and cognitive
behavioral therapy and non-opioid-based therapies, particularly
for people with chronic pain.
Mr. Cummings. My last question. Mr. Turner asked a critical
question, Ms. Enomoto. I guess he was talking about treatment
in prison--is that right?--and what stops you from providing
treatment in prison. Is that what he was asking you?
Ms. Enomoto. Yes.
Mr. Cummings. There is a regulation that says you can't do
that?
Ms. Enomoto. Yes, and I guess I want to check into that so
I make sure I get you a complete and accurate answer.
Mr. Cummings. Yes, please do, please do, because I am
wondering whether it is something that Congress should be
dealing with. I don't know whether that should be in your
control or our control. You follow me?
Ms. Enomoto. Yes.
Mr. Cummings. But I would appreciate an answer as soon as
possible.
Do you know, Mr. Botticelli?
Mr. Botticelli. I do not.
Mr. Cummings. Okay. Thank you.
Mr. Mica. I think Mr. Turner said it is in their control,
and he has a bill to remedy that.
Let me recognize Mr. Walker now. You are recognized, sir.
Mr. Walker. Thank you, Mr. Chairman. I appreciate this
hearing. I appreciate the panel of witnesses being here today.
Mr. Botticelli, you just talked a few minutes earlier about
treatment. I think you mentioned that that is the one thing the
Federal Government could do. Treatment is good, and we need
more of it, but that is reactive after the problem already
exists. Is that fair to say?
So let's start from the very basis. I married into the
medical community. My wife can write prescriptions as a family
nurse practitioner. She works in a Level I trauma center. One
of the things that I have seen as a minister for two decades is
the introduction of marijuana. We heard the statistic today
already that more high school seniors now do weed instead of
cigarettes.
You recently discussed, I believe, the legalization of
marijuana during a 60 Minutes profile, if I remember correctly.
Do you believe that this could potentially lead to future drug
use among the youth?
Mr. Botticelli. I do, and I think the evidence is pretty
clear, that when you are talking particularly about early drug
use by youth, particularly alcohol, tobacco and marijuana, that
that significantly increases the probability that people are
going to have more significant problems later in life. In that
episode I talked about the fact that I and the Federal
Government do not support legalization of marijuana because I
do believe that when you look at the data in terms of the high
levels of marijuana use that we have among youth in the
country, and particularly when we have an industry that is,
quite honestly, targeting our youth with things like funny
cartoon characters and edibles, that we are in for more
significant problems in the United States.
Mr. Walker. Part of our pop culture now, you could say.
Mr. Botticelli. I hear that we are replicating kind of what
has happened in the past.
Mr. Walker. Do we have to worry that legalizing marijuana
could lead to more drug use in the future for not just youth
but for people in general?
Mr. Botticelli. We have been tracking data for the past 40
years, and what it has shown is that when youth perceive using
drugs, and particularly marijuana, as less risky, we often see
an increase in drug use, and not only have we had very high and
historically high levels of marijuana use among youth, we are
also seeing historically low levels of perception of risk of
marijuana use among the youth in our country.
Mr. Walker. And just a question, and then I will let you
go, really quick. I don't want to use all my time here. Does
anybody disagree with the findings of Mr. Botticelli? Just for
the record, does everybody agree that this marijuana usage is
the beginning of what potentially could be a greater problem?
So just for the record, I am seeing everybody say yes, except
for Dr. Wen.
Dr. Wen, you have a different opinion?
Dr. Wen. It is one contributor. Another contributor is our
prescription drug crisis. Eighty percent of people who start
using heroin first start using prescription painkillers.
Mr. Walker. True, but most high school students are not
going to the doctor and getting prescribed major types of pain
relievers. Sometimes their first introduction is through
purchasing marijuana. Is that fair to say?
Dr. Wen. Yes, and also through misusing other prescription
drugs.
Mr. Walker. A nice transition. I do want to come to that. I
want to make sure that we are not painting the doctors as the
bad guys here today. In counseling some of the people who have
gone through some of this, as good people as they are, they
have learned to become master manipulators as far as going into
the various doctors' offices and the emergency rooms. Mr.
Cummings talked about the different pain levels, sometimes the
threshold. Obviously, there are also scoring systems by
customer satisfaction indexes that hospitals have to worry
about.
Dr. Wen, would you speak to that? Is that something that is
fair to say?
Dr. Wen. Most doctors are--by far, the majority of doctors
are trying to do the right thing. And similarly, most patients
are just trying to get the care that they want. Unfortunately,
patients have the expectation that they have to be pain free.
But if I fall down and bruise my knee, I will have some pain.
Getting opioids is not the right answer.
Mr. Walker. I agree, and I love what you said, a pill for
every pain. We have to get away from that culture, as you
mentioned a little earlier.
We have seen kind of a plateau even though it is a large
number of prescriptions. We have to continue to do better, and
I think people in the community--I think of Richard and
Jennifer Kaffenberger in Central North Carolina. They had a son
who had no drugs in his system except one thing. He had played
a football game the night before. He had taken one prescription
pain pill methadone from his grandmother's medicine cabinet,
and it killed him. Sad story, but they have taken that message
throughout all--they are two educators, two teachers in a
middle school in Burlington, North Carolina, and they have
traveled different parts of the state to bring more awareness
of what that can do.
So I am glad to see that that has plateaued, and we need to
continue to stay on top of that, but I am overwhelmingly
alarmed at the spike, and I would like to see those 2015
numbers as soon as those are available of where we are going
with this heroin epidemic. It is something--it is a problem for
all of us, and we have to continue to do more.
With that, I yield back the balance of my time. Thank you,
Mr. Chairman.
Mr. Mica. I thank the gentleman.
Let me recognize now the gentle lady from New York, Mrs.
Maloney.
Mrs. Maloney. I thank the chairman and ranking member and
all of the panelists for focusing on this real crisis in health
care in our country, and it is encouraging to hear your
testimony and the efforts that are taking place in the city,
state, and Federal governments across our country.
But we in Congress need to put money where our mouth is. In
the short term, I urge my colleagues to approve the $600
million in emergency funding which the professionals are asking
for to combat this epidemic. From what I am hearing from Dr.
Wen and others is if we hit the treatment level when they are
becoming addicted to the painkillers, if you hit it then, then
it doesn't get to another level of the opioid. So I think if we
could fund it, that would be important.
Now, the Senate recently acted on this crisis. They passed
the Comprehensive Addiction and Recovery Act of 2016 to help
prevent and treat the opioid addiction, but it does not provide
any funding. So what good is a program, Mayor Jacobs, that
doesn't provide any funding? Does this program help people
suffering in your city or your area?
Ms. Jacobs. Obviously, Congresswoman, funding is a
necessary component of any program that we offer. If I could
add just one thing, because we talked a lot about treatment,
and we have mentioned that that is on the tail end, that is
reactive.
This country came together, it galvanized around tobacco
use, and it profoundly changed the way our youth looked at
that. If this country would come together, if the Congress, if
the state and local level, if we would come together around a
campaign of awareness about how very serious heroin use is,
opioid addiction, painkillers, all of those things, I think we
could make a bigger impact at that level and stem the tide of
this. But it ----
Mrs. Maloney. I think that is a very important point, but
that whole tobacco effort, a lot of it stemmed access. It
stemmed access to tobacco, and they made it more difficult to
have access to tobacco. I know the CDC just came out with some
guidelines that basically say don't prescribe this so easily,
you should have a higher threshold for it, as Dr. Wen said.
When you fall down, you hurt yourself, you bruise yourself, you
are not always completely--you are going to have pain
sometimes. We have to lower the expectation that no one can
have any pain. If you have an operation, you are going to have
pain. It is certainly better to have pain than to become
addicted to heroin or something worse.
But maybe some concrete guidelines on access to it, that
maybe the scientific community should define what pain level
should have access to opioids and that it should not be
something that everyone should expect to be pain free the whole
time they are in a hospital.
How would you react to that, Dr. Wen, to having guidelines
that really stemmed access to very severe pain levels? Because
what we are doing is, for someone to be comfortable for a week,
we are turning them into addicts. I mean, this is a national
health crisis. This has got to stop, and I would say to my
colleagues on the other side of the aisle and on my side of the
aisle, we shouldn't leave here until we vote that $600 million
that is needed for the program. What good is a program if you
don't fund it? It makes it sound like we are doing something
when we are not really doing something. What they need is the
treatment in the field.
But I would like to ask Dr. Wen, what do you think about
reversing it, not just education but giving doctors help in
knowing what threshold of pain would be necessary before this
dangerous addictive drug is allowed?
Dr. Wen. Congresswoman Maloney, thank you for the excellent
point. I agree with you that doctors need further guidance and
tools in order to make the best decisions possible for their
patients, and having guidance would also be useful because we
don't want to punish doctors who are doing the right thing.
Currently, when reimbursement is tied to getting the doctor or
getting the patient to become pain free, that becomes very
difficult for the doctor to practice appropriately.
But I also want to caution that there are appropriate uses
for opioid medications for cancer pain, for surgery, so we
don't want to eliminate that altogether.
Mrs. Maloney. Absolutely. But direct guidelines--now, who
would be the one to do that? The CDC? Have you looked at the
guidelines that they just came forward with?
Dr. Wen. I have, and the CDC guidelines we agree with and
actually hope that they would go further in requiring the co-
prescribing of naloxone, and also in helping us to put further
warnings, including black-box warnings, on benzodiazepines and
opioids, which are the FDA's highest risk recommendation, to
alert both patients and doctors.
Mrs. Maloney. Well, my time is up. Thank you.
Mr. Mica. Let me see. We have Mr. Buck of Colorado. You are
recognized.
Mr. Buck. Thank you, Mr. Chairman.
Mr. Milione, I have a few questions for you. In 1970,
Congress enacted the Poison Prevention Packaging Act to address
aspirin overdose cases with children, and as part of that a
tamper-resistant container was developed for that purpose. We
are now dealing with a situation where there are a huge number
of young people who get these opioids from their parents'
medicine cabinet, and I have been made aware of a product that
I am holding right there that costs less than $1. It would
increase the cost of the prescription less than $1, and it has
a combination on it. It would require the parents to open that.
If a child that didn't have the combination tried to get into
something like this, it would be evident to the parent that
this was opened by someone that didn't have the combination.
Has DEA looked into packaging like this?
Mr. Milione. Congressman, obviously as a father of three,
we support anything that would serve that purpose, and we are
aware of that company and that device.
Mr. Buck. You are probably aware that the company comes
from the great state of Colorado also.
Mr. Milione. I almost said that.
Mr. Buck. Thank you.
[Laughter.]
Mr. Milione. So we are aware of it, and we were happy to
listen to them about that technology. We would support that. We
would support, obviously, the take-back kiosks to get drugs out
of the medicine cabinet. That is a critical part of our overall
strategy. But certainly any technology that would prevent those
dangerous drugs getting in the hands of children or anyone we
would support.
Mr. Buck. And what needs to be done? Do we need a law for
that? And I am not a big proponent of administrative
regulations, believe me; but can you, by regulation, require
that dangerous drugs be dispensed in packaging like this?
Mr. Milione. We can require that they are disposed of. The
regulations cover that, cover the disposal. As far as requiring
how it is dispensed, I don't believe we can. I can certainly
take that back and look at it. We have to navigate somewhat
carefully because if this technology were made widely
available, that would be great, but that would have to come
from a private entity. It wouldn't be something that we would
be able to mandate necessarily.
Mr. Buck. So would you need an act of Congress to require--
obviously we are not going to name a company or a particular
technology, but we would certainly require opioids to be
dispensed in some kind of safe container. Would that be
something that would help you in furthering this goal?
Mr. Milione. It would certainly help prevent it from
getting in the hands of, like you say, children. It is
something we would be happy to talk to you about or follow up
if there was some pending legislation.
Mr. Buck. I would appreciate that very much.
I want to make sure I pronounce this correctly--Mr.
Botticelli?
Mr. Botticelli. Yes.
Mr. Buck. Great. Wow. The Federal Government dispenses
drugs through the VA and other agencies. Again, would it
require an act of Congress, or could the Federal Government,
for purposes of its dispensing drugs to Federal employees or
veterans, use packaging like this without a Federal law from
Congress?
Mr. Botticelli. I don't know that, and similarly, I think
we would have to go back and look at what kind of authority we
would have or if the Federal Government needs additional
authority to do that.
You know, I will say that part of what we have been trying
to do at the Federal level is ensure that every Federal
prescriber at least has some level of mandatory education as it
relates to those. But as far as mandating a package, I don't
know if we either have the authority or we need additional
authority to be able to do that. I could look into it.
Mr. Buck. If you could work with my office on that, I would
very much appreciate that and look forward to working with you
to try to develop this in this area.
I thank the chairman and I yield back.
Mr. Mica. I thank the gentleman.
We will recognize now Mr. Lynch, the gentleman from
Massachusetts.
Mr. Lynch. Thank you, Mr. Chairman.
I do want to associate myself with the words of the
chairman and the ranking member earlier on on this issue. I
think there is much we can do on the treatment side, but up
front, there is also the opportunity to reduce the number of
people who require treatment, and I think we really have to
double our efforts in that regard.
Mike Botticelli, good to see you again.
Mike, for those who don't know, headed up our efforts in
Massachusetts for quite a few years, did great work, and I want
to thank Mr. Milione for the DEA's help. My district has been
overrun, so you have actually been kind enough to assign DEA
officers and agents up in my area, working with our local
police. So we really appreciate the help there.
Obviously, any individual state doesn't have impact on the
border, but you do, so that has been an enormous help for us in
trying to interdict some of the heroin pipeline that has been
coming up into the Boston area.
I had the honor of co-founding the Cushing House in Boston
for Boys and Girls. It is actually an adolescent treatment
facility because our kids are coming in so young with
addictions to both opioids and heroin. We have basically 24
beds for boys, 20 for girls, but the problem is I have a line
out the door, and it is happening over and over and over again.
I do want to say, just as a sidelight here, as I talk to
our young people--and we have put thousands of kids through our
home, and it is a long-term rehab facility. While I don't know
if marijuana is a gateway drug to heroin, every single kid that
I am dealing with who is on opioids and on heroin started with
marijuana. So there is a perfect match, 100 percent. Every kid
I am dealing with for heroin and for opioids, when I ask them
what did you start out with, they all say marijuana. So maybe
there is a susceptibility there or something, I am not sure. It
is not anecdotal; it is more than that. It is empirical, over
thousands of kids, but it certainly points in that direction.
So I think it deserves a cautionary note in terms of some of
this marijuana legalization. I think we are buying ourselves a
huge problem.
One thing I want to talk about and get your opinion, we
haven't talked about the power of these opioids, and I will
give you a couple of examples. A young woman in my district had
a tooth problem. She had an extraction. They gave her a very
large prescription of OxyContin. She consumed that, went back
and complained, falsely she tells me now, of continued tooth
pain, got another prescription, and actually went back in and
complained that another tooth was hurting, which was not. So
she is yanking teeth out of her head just so she could get
prescriptions of OxyContin. That is unbelievable.
I talked to some of my docs in the Boston area, and they
tell me that the chemical changes in the brain, it overrides--
the OxyContin and hydrocodone actually overrides the endorphin
creation in the brain. So it is more powerful than the
endorphins that the brain can produce on its own. So when they
come off that, when they need that, that is why they are going
for more OxyContin or heroin, because that is the only thing
that can scratch that itch.
So we have to think about this. These drug companies are
creating customers for life, customers for life.
Another young father in my district, shoulder pain. Same
deal, gave him too much OxyContin prescription. Two or three
prescriptions later, bam, now he is buying it on the street. A
good dad, good family, just totally fell into that trap.
So we have to figure out--I think it is a huge commercial
advantage for some of these companies to produce a product that
creates a customer for life. We have to think about what we are
doing in that regard. That is a huge commercial advantage.
I think that Governor Baker in the Massachusetts
legislature just came out and said if you are going to
prescribe this stuff, you can only give so many pills, and we
are not going to let you refill them. It is also part of our
drug monitoring piece that we are doing along those lines as
well.
But is there anything on the front end, Mike, that we could
be doing to stop the number of people? Because once they get in
there, we are having a terrible, terrible, terrible problem. We
have a lot of recidivism, a lot of relapse, a lot of money we
are spending for rehab, and we need to do that, I am not
discounting that. But on the front end, to stop these kids from
being trapped, and other unsuspecting patients from being
trapped into this cycle, is there anything else we can do up
front to stop that from happening?
Mr. Botticelli. Sure, and I thank you for that question
because I think it is really important. Again, the CDC just
released guidelines, but they are only guidelines. I agree that
I think the vast majority of physicians and dentists are well
meaning, and part of what Massachusetts has done, 16 other
states, there is legislation in Congress now. We would love to
work with you on mandatory prescriber education because we
feel, again, this is not about bad docs, but they have gotten a
lot of misinformation, largely from drug companies, that these
are not addictive medications, and that we can continue to hand
them out.
I don't think, quite honestly, in the middle of an
epidemic, it is unreasonable to ask a prescriber to take a
minimal amount of education as it relates to safe and effective
opioid prescribing. If you look at the overdoses that we have
seen here, there is a direct correlation between the amount of
prescriptions that we are giving out and overdose deaths, and
this has been going on for 10 years, and I think the medical
community has a role to play, and that is a good starting
point.
Mr. Lynch. What about liability? What about having joint
and several liability for drug companies and the docs that push
this stuff out there? Because these people are unsuspecting and
they are getting addicted like that.
Mr. Botticelli. I agree, and there has been legal action
against Purdue Pharmaceutical for precisely that reason. They
have a role to play not only in terms of making sure they are
meeting the letter of the law about marketing, but also
encouraging abuse-deterrent formulations, another particularly
important area.
We do need to work with the DEA and others to go after
outlying prescribers who are wantonly ignoring the law on this.
But you are right, we need prescriber education, good
prescription drug monitoring programs so physicians can
identify people who might be going from doctor to doctor to do
that.
But to your point, if we are really going to reduce the
magnitude of the problem, we have got to scale back on the
prescribing and identify people who are starting to develop
problems.
Mr. Lynch. Thank you, and I yield back.
Mr. Mica. I thank the gentleman.
Also, Mr. Lynch, I went into one of the drug programs in my
community, talked to every kid I could in the treatment
program. Every kid told me the same thing, he started with
marijuana, then they go on to all the rest of it. So we have a
very serious situation in this country.
Let me recognize--Mr. Walberg is next, the gentleman from
Michigan.
Mr. Walberg. Thank you, Mr. Chairman. I apologize for being
out but Rosie the Riveter showed up at the Capitol and I wanted
to say hi to four of them from my district.
An interesting issue because it does affect all of us. My
district in Southeast, South Central Michigan has tremendous
challenges there, and I appreciate the efforts that all of you
have shown toward this issue.
Mr. Milione, how long has the DEA been aware of the
increased prevalence of fentanyl-laced drugs, and how are you
responding to this problem specifically?
Mr. Milione. Thank you for the question. We have been aware
of fentanyl going back a number of years, and we have seen its
increasing use and have seen it flood the country.
What are we doing? We are doing basically what we do with
all our criminal investigations. We look to target the worst of
the worst, criminal trafficking organizations, identify them,
infiltrate them, indict them, capture, convict them. We are
trying to educate, certainly, our state and locals about the
risks associated with fentanyl. It is a multi-pronged approach,
and it is definitely something we are concerned about.
We certainly are concerned about the unsuspecting users
that are being exposed to it when it is combined with heroin or
when it is put into an exact replica of an opioid pill.
Mr. Walberg. Are those the special enforcement challenges
that you have, or are there others beyond that?
Mr. Milione. There is a whole panoply of different
challenges, and that is certainly one of them. It also poses a
risk to my law enforcement brothers and sisters that encounter
increasingly fentanyl in an enforcement operation. As you know,
it can be inhaled, it can be absorbed through your skin, with
tragic consequences. So it certainly is a major problem for us,
for users, for the country, and then also for law enforcement.
Mr. Walberg. What has the DEA learned about the source of
fentanyl when it appears in heroin?
Mr. Milione. Two primary sources. The majority of it is
coming up from Mexico, with precursors and actual fentanyl
shipped from China, from Asia, into Mexico for production, and
then across the Southwest border, all over the country,
particularly up in the Northeast, but also directly from China.
So those are the two primary threats.
Mr. Walberg. It is my understanding that Mexico has been a
primary source. Is that true?
Mr. Milione. That is true.
Mr. Walberg. How are you working to decrease this
trafficking? Any additional efforts that you can talk about in
regards to what is coming across the border?
Mr. Milione. We have a great relationship with one of our
largest, if not our largest, office in Mexico. We have a great
relationship with our counterparts. We continue to work with
them on those trafficking organizations. The Sinaloa Cartel is
probably the most powerful cartel down there. It has a
tremendous distribution network spread across the country. They
are capitalizing on the prescription opioid abuse epidemic.
They are flooding the country with heroin, but they are also
now flooding it with fentanyl.
So we are just going to continue an aggressive approach
from the law enforcement side and do what we do with our state
and local counterparts every day.
Mr. Walberg. Okay. Mr. Botticelli, what efforts is the U.S.
engaging in to work with governments where heroin is produced
to cut off the supply? And then secondly, does this involve
identifying labs in countries like Mexico which may be a
trafficking bonanza of heroin and fentanyl in the United
States, and what are the biggest barriers to stopping that?
Mr. Botticelli. As we have looked at this issue,
particularly heroin and fentanyl, having an aggressive approach
that reduces the supply is particularly important. I actually
was just in Mexico a few weeks ago meeting with the Attorney
General and high-level folks in the government, calling for
enhanced action particularly as it relates to heroin, looking
at enhanced eradication efforts, looking at how we go after
both heroin and fentanyl labs, and how we continue to support
mutual collaboration in going after the organizations that deal
with it.
We have also been working with the DEA and our high-
intensity drug trafficking areas domestically to look at
reducing and going after those organizations that are
trafficking heroin and fentanyl domestically. I think it is
really important for us to have this holistic approach and to
really focus on a robust law enforcement response to reduce the
availability of heroin and fentanyl.
We have to really look at how we work with our Customs and
Border Protection folks to increase the detection of both
heroin and fentanyl. And I think, to Mr. Milione's point, we
have to look at our international work with China that often
produces these precursor chemicals as it relates to
particularly fentanyl production.
We were actually pleased that China just moved to schedule
over 130 new substances, including one of the precursors,
acetyl fentanyl. So it really is important for us to work with
our international partners, particularly China, Mexico, and
working with our domestic law enforcement folks.
Mr. Walberg. Thank you. I yield back.
Mr. Mica. I thank the gentleman.
The gentleman from Pennsylvania, Mr. Cartwright.
Mr. Cartwright. Thank you, Acting Chair Mica, and thank you
to all the witnesses for coming today. I have listened to all
of your testimony, and it is well taken.
I come from Pennsylvania. In Pennsylvania, hospitalizations
for overdoses due to pain medication increased 225 percent from
2000 to 2014. Drug overdose deaths in Pennsylvania increased by
12.9 percent between 2013 and 2014, compared to a 6.5 percent
increase nationally in the same time period. It is a huge
problem in Pennsylvania.
Director Botticelli, you mentioned attending a town hall.
Earlier this year I did a town hall in my district in Coaldale,
in Schuylkill County, Pennsylvania. It is a rural place.
Typically we get between 30 and 40 people out for routine town
halls. At this one, we had over 100 people come out, and nobody
was smiling. Every family is touched by this crisis, by this
epidemic.
The question is, what can be done to combat it? In
Pennsylvania, there is a company, Iroko Pharmaceuticals, that
is right now using nanotechnology and is following the FDA
directive to use the lowest effective dose of NSAIDs for
chronic pain. Iroko is an African American-owned company which
is growing by the month, providing not only jobs in
Pennsylvania but also a logical solution to our national opioid
epidemic.
I also believe there are legislative solutions to help
address the issue, like H.R. 953, the Comprehensive Addiction
and Recovery Act. This was introduced in the House by
Representative Sensenbrenner of Wisconsin. In the Senate, the
same bill was introduced by Senator Whitehouse of Rhode Island.
That bill passed the Senate, and in the House I am a co-sponsor
of 953. It is a bill that would adjust existing authorizations
and programs to provide a series of resources and incentives to
help health care providers, law enforcement officials, states
and local governments expand drug treatment prevention and
recovery efforts, and throw funding toward those efforts. I
wish to urge Republican leadership to move H.R. 953 to the
House floor for a vote. It is a concrete step we can take in
the right direction.
Now, my colleague, Mr. Lynch, talked about New England, and
the New England area has been referred to as ``the cradle of
the heroin epidemic'' by the New York Times, and I see you
nodding your head, Mr. Milione. You are aware of that, I take
it.
Mr. Milione. Yes, sir, I am.
Mr. Cartwright. According to the DEA's 2015 National Heroin
Threat Assessment Summary, 63.4 percent of New England law
enforcement agencies reported heroin as their greatest drug
threat. And just last week, Governor Charlie Baker signed
legislation making Massachusetts the first state to pass a
statewide cap on first-time opioid prescriptions.
My question is, with the rising number of opioid deaths,
what steps has DEA taken to collaborate with the state and
local law enforcement agencies to reduce opioid overdoses and
deaths?
Mr. Milione. Congressman, thank you for the question. Under
the leadership of our Special Agent in Charge up there, Mike
Ferguson, they have a great relationship with the U.S.
Attorney's Office, and they have brought together all the
different elements--state, Federal, local, working with the
health community--to identify where the hot spots are, and then
to do the community outreach piece, but then also to do the
enforcement on the groups that are trafficking in those
substances.
Mr. Cartwright. Okay. And, Director Botticelli, how is the
Federal Government working to encourage and support innovative
ideas by the states to combat the opioid epidemic?
Mr. Botticelli. I think there are a number of ways that we
are doing that. One, looking at funding opportunities to
provide states with the opportunities to really create
innovative strategies. One of the things that our office does
is really look at how do we promote some of these innovative
things that are happening at the state level. So whether that
is law enforcement that are working to get people into
treatment, or things like the 24/7 triage programs.
So part of what the Federal Government's response is is
ensuring that states and locals have the resources they need to
continue to implement programs that address these issues.
Secretary Tennis in Pennsylvania I think has really
demonstrated some really strong leadership in terms of the work
that is happening here. I talk with the Secretary just about
every day in terms of looking at what more the Federal
Government can continue to do.
But I think the largest function that we have is making
sure that states and locals get the resources they need to
continue to develop and show leadership on this issue.
Mr. Cartwright. Well, amen to that, and I yield back, Mr.
Chair.
Mr. Mica. I recognize Mr. Hice from Georgia.
Mr. Hice. Thank you, Mr. Chairman.
The CDC in Georgia has a report that Georgia alone has seen
a 10 percent increase in overdose deaths. I am sure you have
seen that in the last couple of years. To me, this is
especially alarming just for the fact that high school students
are using painkiller medication at alarming rates which makes
them 40 times more vulnerable to use heroin.
The DEA said that heroin is currently available in larger
quantities, that it is used by a larger number of people, and
that it is causing an increasing number of overdose deaths. Is
that correct?
Mr. Milione. Yes, sir.
Mr. Hice. I want to focus on where this stuff is coming
from. So, Mr. Milione, let me start with you. From your
testimony regarding the DEA's new 360 Strategy, which you
referred to a little while ago, it sounds to me like the DEA is
going to focus less on the Mexico-based organizations that are
trafficking heroin and focus more on the street gangs that are
distributing heroin. Is that a correct assessment?
Mr. Milione. Congressman, it actually is not. We are more
nuanced than that. We are never going to go away from our core
mission of working up the chain to the cartel leaders in
Mexico. So the 360 focuses on the link point, the link point
that bridges the violent distribution cells domestically that
are affecting the communities, and also the cartels that are
flooding the country with the heroin. So it absolutely is not
one or the other. It is a comprehensive approach.
Mr. Hice. So is there a greater emphasis, though, on the
distribution side of things now?
Mr. Milione. I wouldn't say there was necessarily a greater
emphasis. It is a shift of focus so that we can do everything
we can to get the violent distribution cells under control and
give the communities back their communities.
Mr. Hice. Is it fair to say from your assessment that our
interdiction efforts with the cartels have failed, or at least
not been as successful as we had hoped?
Mr. Milione. Congressman, I wouldn't characterize it as a
failure. Interdiction is one part of it, but what we are
focused on at the DEA is going after the actual individuals
that are selling the powder, that are pushing it, the
infrastructure, the corrupting influence, the money. Those are
the things we are focused on. Interdiction is one piece of
that.
Mr. Hice. All right. Sounds to me like you were just then
saying that the emphasis is going to be on the distribution
side of things.
Mr. Milione. No, I don't believe I said that it was just
going to be on the distribution. It was going to be on ----
Mr. Hice. I didn't say ``just,'' but the emphasis.
Mr. Milione. There is going to be an emphasis on the
distribution, and also on the supply side.
Mr. Hice. Okay. You mentioned a while ago--and I will just
shake my head with all of this, because we have been into this
war on drugs forever, and it is getting worse. We are not
making any headway on this. You mentioned just a while ago that
we have a great relationship with the Mexican government and
that that relationship--the reality is that heroin is coming
across the border more now than it ever has. What good is a
great relationship if we are not addressing the problem? At
some point, this thing is getting worse and worse and worse,
and we are throwing more and more money to it all the time. It
frankly doesn't appear to me as though anything is happening to
stop the problem that would go to the point of what you said a
while ago, that we are addressing this aggressively.
Mr. Milione. Congressman, as somebody who has served for 20
years and has seen the sacrifices that the brave men and women
of the DEA do every day, and dangerous situations in the
country, and also in the foreign arena, we are doing everything
we can to deal with this very, very difficult and complicated
problem. We are working to reduce demand, but we also have to
go after the organizations that are flooding our country.
So the war on drugs is not necessarily a phrase that we
would use. We do criminal investigations in highly dangerous,
sophisticated cartels operating ----
Mr. Hice. Well, I take my hat off to those agents who are
out there in the field, and I am not in any way belittling
them. But for us to come in here and somehow try to give a
picture that we are aggressively dealing with the problem when
in reality it is getting worse and worse is putting forth a
false image.
Mr. Milione. I would have to disagree with the false image.
Mr. Hice. Well, you can disagree all you want. The fact is
the problem is getting worse. You yourself have admitted that.
Mr. Milione. Congressman, I don't disagree that it is a
difficult problem and that there are parts of it that are
getting worse, but I am not painting a picture that is
inaccurate when I say that we are aggressively doing everything
that we can, at tremendous sacrifice.
Mr. Hice. So how many criminals have been arrested and
prosecuted under DEA's Rolling Thunder program?
Mr. Milione. I can't give you the number of arrests. I can
tell you that there are 448 investigations in 125 cities around
the country.
Mr. Hice. But you don't know how many arrests?
Mr. Milione. I would have to get back to you with any
specific statistics.
Mr. Hice. Please get back to me.
Mr. Chairman, I see my time has expired.
Mr. Mica. I thank the gentleman.
The gentleman from California, Mr. DeSaulnier, you are
recognized.
Mr. DeSaulnier. Thank you, Mr. Chairman.
First of all, I appreciate the panel. I think all of us
have stories about constituents who have been affected by this,
and the frustration I think of some of my colleagues at our
inability as a country to deal with the drug problem, no matter
what we have tried.
I would like to ask a couple of questions on the opiate
side. I have one constituent who came to me and made me aware
of her personal situation where her son was going to school at
the University of Arizona and drove to Los Angeles with some
other students to actually go to a doctor in Los Angeles and
then overdosed. This doctor was just recently convicted,
multiple convictions in Los Angeles.
I have another constituent who went out to walk to a Baskin
and Robbins on a Sunday afternoon, and one of his two kids was
killed right in front of him when a woman who had been abusing
opioids and drinking came across. So all of us have those
stories, unfortunately.
One of the things we were able to do in California--and Mr.
Lieu and I were part of this in the legislature--was update our
prescription monitoring system. So my question is really around
electronic health records. I would talk to doctors and they
would say, well, electronic health records are right around the
corner. Doctor shopping will be a thing of the past. We worked
with the Attorney General in California, and that process is in
effect now, but we are just waiting to see how effective that
is.
So, Mr. Botticelli, maybe you could tell us--and one of the
frustrating things, of course, is when you have this patchwork
of different states doing different things, it seems to me that
it would be fairly efficient for the Federal Government to
provide the infrastructure for a nationwide electronic
monitoring system so that the Department of Justice in all 50
states and the Federal Department of Justice would have red
flags so that they would see if a doctor, like the doctor in
Los Angeles, is abusing his or her privileges, or if a client
is doctor shopping.
Mr. Botticelli?
Mr. Botticelli. Prescription drug monitoring programs have
been part of our main emphasis since the beginning of this
epidemic, and I think to your point, we are seeing a tremendous
amount of success. When we started we had only 20 states that
had effective prescription drug monitoring programs, and now we
have 49 states that do that. We actually thought it was more
prudent, because we had so many states that already had an
existing program, to really look at the state level.
But to your point, I think what we are trying to focus on
next is interstate data sharing so that states can talk to one
another, and interoperability with electronic health records,
because that is the next phase of--we want to be responsive to
physicians in terms of the burden of workload and look at how
do we get timely information to them by supporting that. So we
have been working with HHS and others. This is an important
priority for governors as well, so we have been talking to the
National Governors Association in terms of what states can do.
But this has really been one of the more effective tools
that we have seen, but we also need physicians to use them. So
part of this is, again, I think we are very interested in
states that have passed not only mandatory education but, like
Massachusetts just did, checking the prescription drug
monitoring program not only at first dispensing but at every
dispensing ----
Mr. DeSaulnier. So it is mandatory.
Mr. Botticelli. So they are only as good as when people use
them.
Mr. DeSaulnier. And, Ms. Enomoto, maybe you could talk to
this. In Northern California we have a lot of Kaiser clients.
So there you have a closed system where there is still a
problem, so there is a financial aspect to this. For them, if
they were able to use electronic records both for the cost and
efficient use of the system, but also to protect the clients
from being either over-prescribed or clients taking advantage
of the system, how far away are we from having a real strong
electronic monitoring system that can do both?
Ms. Enomoto. You know, I think we are seeing in some states
already great progress. So in 2012, SAMHSA had the opportunity
to issue grants for the enhancement of prescription drug
monitoring programs that focused on both the interoperability
with EHR as well as interstate interoperability. In those
grants, during the period of the grant, we got six out of the
nine states that were able to achieve that level of
interoperability, and then post-grant we have two more states
who are now online with their MOUs so that they should be able
to start exchanging information with their EHRs very soon. So
out of a relatively small investment, partnering with CDC,
partnering with the Office of the National Coordinator and
ONDCP, we were able to get eight out of nine states to achieve
that level of interoperability.
Mr. DeSaulnier. And lastly, the statistics always come to
mind. The U.S. has about 5 percent of the world's population,
but we use over 80 percent of the opiates. How much of this is
the criminal aspect of it, Mr. Botticelli?
Mr. Botticelli. I would actually say very little. Again, I
think this has been a concerted effort by the pharmaceutical
companies to falsely promote those medications. In 2013, we
prescribed enough prescription pain medication to give every
adult American a bottle of pain pills, and I think that is why
the CDC guidelines become so important, looking at not having
opioid therapy as a first-line defense for chronic pain, really
supporting when you do start with opioids for some people who
do need them, starting with the smallest, the lowest dosage and
the smallest possible amount, because I really do believe that
we have made progress in many areas, and I don't believe that
we have made enough progress in really implementing safe opioid
prescribing behavior.
Mr. DeSaulnier. Thank you.
Thank you, Mr. Chairman.
Mr. Mica. Thank you.
Let me recognize now Mr. Carter from Georgia.
Mr. Carter. Thank you, Mr. Chairman. And thank all of you
for being here.
I have been kind of in and out. I apologize. I had three
committee meetings at one time, at the same time. But I want to
associate myself, first of all, with all the comments that have
been made about marijuana being a gateway drug and leading to
drug abuse. I could not feel more adamantly about that, so I
just want to make sure everyone understands that.
For those of you who don't know, I am a pharmacist, not
practicing anymore. The only pharmacist in Congress. I have
over 35 years of experience, and a lot of experience with
opioids as a dispenser. I am very blessed that I have never
taken any drugs, never had that. I am human and I have
weaknesses, but that is not one of them, and I feel very
strongly about that.
I want to start with you, Mr. Milione. This is very
uncomfortable, but I will tell you that almost a year ago, a
little over a year ago, in fact, in Tampa, a judge ruled
against the actions of the DEA when you raided a compounding
pharmacy. You destroyed the medication and completely shut down
the pharmacy without any real cause. This was Westchase
Pharmacy in Florida. Are you familiar with that situation?
Mr. Milione. I am not.
Mr. Carter. You are not? Well, you need to be because, let
me tell you, this is not a shining example that you want to
point toward. This is an example where one of the supervisors
that you oversee conducted a raid and at the time had no
experience in diversion investigation, hadn't read the DEA
handbook, yet raided a compounding pharmacy with tactical gear
and guns, shut down the business, seized hundreds of thousands
of dollars of medicine, and improperly stored them, therefore
rendering them useless, all because the DEA misinterpreted and
failed to follow their own laws. This is, as the judge said,
preposterous, and this is not going to be accepted.
Now, look, I support the DEA. I don't like anybody in
health care who is not practicing by the best of standards. We
have bad pharmacies out there, we have bad pharmacists, we have
bad doctors. Dr. Wen, there are bad doctors out there. You
can't paint with a broad brush. There are bad actors in every
profession. But this kind of action, this kind is totally
unacceptable, Mr. Milione, especially when we have someone
coming to your pharmacy bearing guns. That is unacceptable. So
I hope you will look at that. It is Westchase Pharmacy. I hope
you will research that and understand that.
I want to ask you, Dr. Wen especially, we have talked about
opioids being used as the entry-level drug for pain control.
One of the problems that I see here--and, Mr. Botticelli, you
and I have worked together before. You know I sponsored the
legislation in the Georgia State Senate to set up the PDMP for
Georgia. But one of the problems I see is with the FDA taking a
lot of the products off of the market.
Now, specifically I want to talk about propoxyphene. You
know, propoxyphene was on the market for years and years. I
can't imagine how much I dispensed in my career. But I will
tell you, when they took it off, what did it do? It led people
to opioids. That is the only choice the doctors had. What do
you do now? You have ibuprofen and acetaminophen. That is where
you want to start.
Well, let me tell you, as a practicing pharmacist I can
tell you, you try to get a patient to take something that is
available without a prescription, you are not going to be able
to convince them that it is going to work. You have to have a
prescription for it. That is just the way it is. No, it is not
right, but I will try as hard as I can, and I can't convince
them of that.
And just like the propoxyphene, don't give me that white
one, only the pink one works, that is the only one that works.
That is what you are dealing with.
But one of the problems, I think, has been the FDA taking--
and I know that propoxyphene had its problems. I am not trying
to question that. But what I am trying to point out is that we
need more entry-level drugs, something in-between the opioids
and ibuprofen and acetaminophen. That would be better. The CDC
guidelines that have come out, the prescribing guidelines for
doctors, I think that is very, very helpful. It needs to be
enforced more. It needs to have some kind of teeth in it.
I am running out of time here because I want to get into so
many things.
Another problem is mail-order pharmacies sending these
gigantic containers of opioids to the doorsteps of people,
leaving them on the doorsteps for them to be--who knows what is
going to happen to them. You get a 90-day supply. I have people
bringing them now to the drugstore my wife now owns. They bring
into those drugstores all the time giant containers of opioids.
That needs to be suppressed, Mr. Milione. The DEA needs to do
something about that. That is ridiculous and something that we
need to address as well.
The last thing I want to talk about is 21st Century Cures
and the locking provision. Listen, I am a big proponent of 21st
Century Cures. I think it is some of the best legislation we
have passed here since I have been in Congress, and I support
it, and I voted for it. However, that locking provision is very
dangerous and I think it needs to be looked at. You have a
relationship between pharmacies and patients, between doctors
and patients. When you get into a locking provision, it is
going to be very, very difficult, because you need pharmacists.
You need pharmacists to participate in this and help us to curb
this problem because it is--let me tell you, I have seen it
ruin families, I have seen it ruin lives, I have seen it ruin
careers, and it is worse than can even be imagined at this
point.
Mr. Chairman, I know I have gone over, and I apologize.
Thank you.
Mr. Mica. Thank you.
The gentleman from Virginia, Mr. Connolly.
Mr. Connolly. Thank you, Mr. Chairman.
I will say, Mr. Mica and I had a series of hearings in the
previous Congress on U.S. drug policy that included marijuana,
and it forced me to reexamine some things I thought I knew or
believed about our drug policy with respect to marijuana. But
what is disturbing to me, if there is a gateway drug to heroin,
it is opioid prescription drug addiction far more than
marijuana, and that is why this hearing is so timely. It is
affecting every community we represent here in this body. It is
not a rural phenomenon or an urban phenomenon or a suburban
phenomenon.
Well, let me ask you, Mr. Botticelli, how did we get to
this point? I mean, I don't want any doctor to leave a patient
in pain. Serious pain is a terrible affliction, and first you
do no harm. But how do we draw that line between pain
management and just an unbelievable avalanche of prescriptions
for opioids that has now led to an epidemic of addiction in
America? With, presumably, the best of intentions originally.
Mr. Botticelli. I agree, and I think when you look at the
roots of this epidemic and what are the significant drivers,
yes, there are other issues going on. It is really about the
over-prescribing of these very addictive pain medications that
we have.
Mr. Connolly. But why? How did we get there? Doctors aren't
stupid people.
Mr. Botticelli. Well, I think that doctors were given a
significant amount of misinformation from pharmaceutical
companies, and even from the medical professions themselves,
that these were not addictive medications. So that was really
the start of this, that despite scant scientific evidence,
there was this full court press to basically educate
physicians, saying that these medications were not very
addictive, and at the same time we had what I think is a very
noble and should be a noble goal, that we have to do a better
job at pain treatment in the United States, that there are a
lot of people who have significant pain and who need it.
So I think you had this confluence in terms of really a
full court press to treat pain--the VA even talked about pain
as the fifth vital sign--and little education on the part of
these prescribers about how addictive these substances were,
about how to identify people. So physicians in the United
States get very little training on appropriate pain
prescribing. I think there was a GAO study that showed
veterinarians actually get more training on pain prescribing,
and physicians get little to no training on substance use
issues.
So I think it was this kind of mixture of a whole set of
factors that really drove up addiction and overdose in the
United States, and now we have that compounded by heroin and
fentanyl availability.
Mr. Connolly. Dr. Wen, what is effective treatment? I mean,
what is the system for recognizing somebody has a problem and
we need to get them treatment? What is efficacious treatment in
trying to turn this around early before it moves on to, say,
heroin or something worse?
Dr. Wen. It is often said that medicine is an art and not
completely a science because even something like pain is
subjective. What is a pain for you is not the same for somebody
else. So that is why doctors do need discretion about how to
treat each individual patient based on their symptoms and who
they are, also recognizing that it is not just about
medications. We also have to do physical therapy and counseling
and education that sometimes pain is okay. We don't have to
treat everything with a pill.
So we very much agree with the increase in the use of
PDMPs, recognizing that some PDMPs are very cumbersome to use.
If I am seeing 40 patients in eight hours, I can't be spending
an hour of that time figuring out how to get into every
patient's PDMP.
Mr. Connolly. Got it, but we are running out of time. So
what is efficacious treatment? What do you recommend in the
Baltimore Health Department?
Dr. Wen. We recommend, first of all, judicious use of pain
medication so that we are not ----
Mr. Connolly. I get that. I am talking about treatment. We
have a problem; what is the treatment? What is efficacious?
What have we learned? Because, look, we are policymakers up
here. We want to solve a problem. We get that part. But if we
have gotten to the point where we have an addictive problem but
we are trying to prevent that person from going on to the
heroin part, what works? What, in your experience, works by way
of intervention?
Dr. Wen. One thing, recognizing that addiction is a
disease, and therefore we have to get people into addiction
treatment, which is medication-assisted treatment, psychosocial
counseling, and wraparound services. We know that the World
Health Organization shows for $1 invested in treatment, that
saves $12 for society, and that is something we should invest
in.
Mr. Connolly. Thank you very much.
Thank you, Mr. Chairman, and thank you for the hearings you
and I held. They were quite informative ----
Mr. Mica. I believe the only ones in Congress, and we got
criticized for them.
Government Operations, he was my ranking member, and then
years ago with the ranking member here.
Mr. Connolly. Thank you again, and thank you to the panel.
Mr. Mica. The gentleman from Wisconsin, Mr. Grothman.
Mr. Grothman. I will yield my first minute to Mr. Carter.
Mr. Carter. I thank the gentleman for yielding.
I would be remiss if I did not mention next week in Atlanta
we are having the National Prescription Drug Abuse and Heroin
Summit. Representative Hal Rogers from Kentucky, who has been a
champion for this, is a co-chair of that. I hope that you will
be there. I hope that my colleagues will be there. This is an
opportunity to learn more about prescription drug abuse. It is
a great, great summit, and I encourage everyone to attend.
Thank you.
I thank the gentleman for yielding.
Mr. Grothman. Anytime.
Okay, now I have a question. One of the things that bothers
me is the legal prescription of opiates. I had two minor health
things in my life in the last two years that I had earlier in
my life. Both times, the medical professionals were willing to
give opiates, like a month's worth of opiates, for something
that had no business under any circumstances prescribing
opiates, and they wouldn't have five years ago.
I guess I will start with Mr. Botticelli, but anybody else
can chime in here. What can we do to stop, in these basic
things--I would say what they were, but I don't want to
embarrass the medical professionals. They were par for the
course. I mean, one of the things is we are not going to
reimburse for Medicaid, we are not going to reimburse for
Medicare, we are not going to reimburse anything else the
Federal Government is kicking in for these sorts of problems,
no matter how much pain you claim you have, because people
never used to have it. Or we could perhaps say even for CMS. We
are just not going to reimburse across the board. And if we are
going to reimburse, it is for three days, none of this month's
prescription stuff.
Is that something that could be done? I don't think we can
give the medical professionals a lot of wiggle room here
because they have shown in the past they abuse that wiggle
room.
Mr. Botticelli. I think there are a number of things that
we can be doing. I think, one, you are right, there are
opportunities to work with not only CMS but private insurance
as well with that.
Mr. Grothman. Why don't we do it?
Mr. Botticelli. CMS actually sent out a letter to state
Medicaid directors this summer to really look at putting in
place prescribing protocols around that. I also think that we
really need to continue to focus on mandatory prescriber
education. I am not a big fan of government mandates around
that, but I do think, again, that we really need to educate the
medical profession about safe and effective opioid prescribing.
Mr. Grothman. All you need--I don't mean to cut you off.
All you need is a little common sense. I mean, if we have that
many people in the medical field that lacking in common sense,
we have a bigger problem than lack of education.
Mr. Botticelli. I don't think it is a matter of common
sense. I think it was a matter of the medical profession, very
well meaning to the largest extent, who were given
misinformation on the lack of addictive properties of these
drugs, and it was really a full court press to more
appropriately treat pain with a prescribing community that gets
little to no training on appropriate pain prescribing.
Mr. Grothman. Well, 90 percent of the people on average in
Wisconsin know this is all screwed up. I can't believe that the
medical professionals need training on this, but okay, if you
say they need training.
Now I want to come around to the penalty thing, Mr.
Milione. I got here late, didn't hear your name. It seems to me
that the penalties for people who sell heroin is not as high as
it should be, or they are not going to prison as long as
possible. One of the problems I have is a lot of this is local
stuff, it is not a Federal issue. But I assume we do arrest
people. The Federal Government arrests people who possess
heroin, at least enough that you can assume that they are
dealing in that drug.
Do we arrest people for that? And if we do, what is the
recommended sentence?
Mr. Milione. Congressman, at the DEA at the Federal level
and in our task forces, we are not focused at all on users or
simple possession.
Mr. Grothman. I am not saying possession. If you get
somebody with enough heroin, which isn't very much, that you
know it can't be for personal consumption, you know they are
going to be selling for somebody, what do you do with that
person?
Mr. Milione. I can't really give you a quick answer like
that. It depends on the investigation and obviously in
conjunction with the Federal prosecutors we work with, the
state prosecutors. They look at the conduct, and then
ultimately a judge decides what that sentence is going to be
based upon the guidance that the judge gets. That is the
clearest answer I can give you. It is not a very clear answer.
Mr. Grothman. It is a very muddy answer, yes.
Mr. Milione. Yes, but it is the world we live in.
Mr. Grothman. Okay. I will give you one more quick
question, then I will hang around here to see whether the
Chairman eventually can call on me again if I wait long enough.
What do they do in other countries on this? I toured
another country 10 years ago and I asked about a drug problem,
and they told me the criminal penalty for these severe drugs
was shockingly high. I won't say what it was because it might
have been wrong, shockingly high.
What do they do in other countries to make sure they don't
have this big opiate abuse, say in Southeast Asia in some of
these countries where they don't want to have a penalty, so
they hand out?
Mr. Botticelli. It is interesting that you say that. I
actually just returned from--there is a U.N. group of my
colleagues from around the world in terms of looking at the
global approach to drug policy, and I think that there is an
emerging consensus with the vast majority of the countries that
we need to continue to focus on an enhanced public health
response, that while law enforcement plays a key role for some
of our major traffickers, that we need to look at and continue
to explore alternatives to incarceration.
So I think that there is a kind of consensus among
countries ----
Mr. Grothman. I don't mean to cut you off. I am well past
my time, and because I am past my time, I would like it if you
would answer my question, okay? I know that there are a lot of
people out there who like this public health response, okay? I
am under the impression that we put people in prison for a
reason, okay? Other countries have very large penalties and
much less of an opiate problem. Could you tell me what their
penalties are?
Mr. Botticelli. Well, I think they probably have less of an
opiate problem because in many parts of the world most people
actually don't have access to medications at all. So it is not
a function that they have criminal penalties.
Mr. Grothman. No, you are wrong. But just tell me what they
are because these are countries that are fairly advanced, and
they don't have an opiate problem, and part of it is the
penalties are pretty dramatic. Do you know what these penalties
are, say in places in Southeast Asia?
Mr. Botticelli. I don't, but I can tell you that Southeast
Asia considers labor camps part of their treatment regimen. So
I wouldn't necessarily equate drug policy around there as it
relates to their drug problem.
Mr. Mica. Thank you. I think in Singapore they also execute
them.
Mr. Lieu from California, you are recognized.
Mr. Lieu. Thank you, Mr. Chairman.
Mr. Botticelli, thank you for your public service. I have a
few questions for you. Let me begin by saying that the current
heroin and opiate epidemic has some similarities to the crack
epidemic of the 1980s. Unfortunately, our response back then
was to increase prison sentences. I am pleased to see we are
taking a different approach this time, and America is finally
starting to realize that drug addiction is primarily a disease.
One of the most noticeable differences between the crack
epidemic and the opioid epidemic is that the crack epidemic
mostly affected poor communities of color, but the face of the
opioid epidemic is very different. According to a study
published in Journal of the American Medical Association,
nearly 90 percent of the people who tried heroin for the first
time in the past decade are white. Does that statistic sound
largely correct to you, sir?
Mr. Botticelli. It does.
Mr. Lieu. I have an article here in the New York Times
titled, ``In Heroin Crisis, White Families Seek Gentler War on
Drugs.'' In that article you are quoted as saying, ``Because of
demographics, the people affected are more white, more middle
class. These are parents who are empowered. They know how to
call a legislator. They know how to get angry with their
insurance company. They know how to advocate. They have been so
instrumental in changing the conversation.'' You said that,
correct?
Mr. Botticelli. Correct.
Mr. Lieu. So I believe that it is important that we need to
address these issues among the white middle class, but I want
to make sure also that our resources are directed across the
country regardless of socioeconomic or race status. My question
to you is how to ensure that Federal resources are applied
fairly and match the unique issues facing individual
communities.
Mr. Botticelli. Thank you for your comment. It is a really
important issue to me and to you and Congressman Cummings. I
have been doing this work for the better part of my life, and I
am glad that in this country we are finally at a point where we
have acknowledged the disproportionate impact on people of
color and poor folk in terms of this issue, and I am glad we
are at a different place. I am glad that we have now a huge
political movement that is happening with people around the
country to call for a different response.
I completely agree. I think that we have to make sure that
the policies that were implemented, that the programs that were
implemented are targeted at those communities that have the
most pressing need, and that when we talk about things like
criminal justice reform, we are talking about criminal justice
reform for everybody, regardless of color, as it relates to
this, that our human response to this epidemic needs to be a
human response for everybody and not just for the 90 percent of
white people who are affected by this issue.
I am glad we have learned a lot over the past 40 years in
response to failed drug policies in the past. I am glad we are
at the place where we are finally acknowledging that this is a
disease and that we can't make our jails and prisons our de
facto treatment programs for anybody.
So I feel a tremendous responsibility in terms of making
sure that we use this moment in time where there is broad
acknowledgement of the fact that this is a disease and that we
can't arrest and incarcerate, that we implement those policies
and programs for everybody.
Mr. Lieu. Thank you for that answer.
Mr. Chairman, I would like to enter for the record the New
York Times article, ``In Heroin Crisis, White Families Seek
Gentler War on Drugs.''
Mr. Mica. Without objection, so ordered.
Mr. Lieu. There have been anecdotal stories today that
marijuana is a gateway drug. Are you familiar with an article
in Time magazine that says, ``Marijuana as a Gateway Drug, the
Myth That Will Not Die''? Have you read that article?
Mr. Botticelli. I don't know if I read that.
Mr. Lieu. So let me quote from it. It says, ``Scientists
long ago abandoned the idea that marijuana causes users to try
other drugs. As far back as 1999, in a report commissioned by
Congress to look at the possible dangers of medical marijuana,
the Institute of Medicine of the National Academy of Sciences
wrote there is no conclusive evidence that the drug effects of
marijuana are causally linked to subsequent abuse of other
illicit drugs.''
Now, it is true there is a correlation, and this article
and the study explains that underage drinking of alcohol also
has a correlation, that those that actually use typically
precedes marijuana, and that marijuana is not the most common
and is rarely the first gateway illicit drug use. And then this
article goes on to say why there might be a correlation, and
one simple reason is that people who are extremely interested
in altering their consciousness are likely to want to try more
than one way of doing it. So if you are a true music fan, you
probably won't stick to listening to just one band. That
doesn't make lullabies a gateway to the Grateful Dead. It means
people who really like music probably like many different songs
and groups.
So isn't it correct that there is no scientific evidence
that marijuana is a causal link to illicit drug use?
Mr. Botticelli. I think the evidence is pretty clear that
early use of alcohol, tobacco and marijuana, often used
together, significantly increases the probability that someone
will develop a more significant addictive disorder later in
their life, and I think that the more younger people use, the
more that those chances grow.
I also think that the music analogy is kind of inaccurate
in this situation because early substance use actually affects
brain development, not just affects people's taste, and it
actually affects people's brain development and predisposes
people for more significant vulnerabilities later in their
life.
Mr. Lieu. Thank you. My time is up. I will send you the
article on that issue also.
Mr. Chairman, if I could enter into the record the Time
magazine article that says ``Marijuana as a Gateway Drug, the
Myth That Will Not Die.''
Mr. Mica. Without objection, so ordered.
Mr. Mica. The gentle lady from New Mexico, Ms. Lujan
Grisham.
Ms. Lujan Grisham. Thank you, Mr. Chairman.
I have no doubt that we will continue in Congress, and
localities and cities and states will continue the debate about
gateway drugs. Certainly, I participated in many of those
discussions about alcohol, which is really the foundation in
terms of creating an environment where you put yourself more at
risk, particularly adolescents and adolescent drinking. I come
from a state, unfortunately, that has some of the highest drug
abuse rates and the highest overdose rates in the country.
Mr. Botticelli, I appreciate very much you raising the
issue in your testimony and talking about there is now a very
direct and specific correlation between the number of
prescriptions that have gone up and the number of prescription
drug issues, which we are trying to deal with today. And I
would hope that Congress undertakes an effort, when we are
combating the opioid problem, that we look at drug issues in
general, drug policy in general, and certainly continue to
debate and work on criminal justice reform so that we are
focusing on both prevention and effective treatment, which is
really the way to get at it.
I also want to say I appreciate the panel and members'
questions. I am in a state that just passed legislation that
would make naloxone available to far more than just the medical
providers and prescribers, that we want it to be in the jails,
we want first responders, and first responders to include
family members in close proximity so that we can prevent
overdose deaths. In a state that has a Republican House and a
Democratic Senate, there was great bipartisan effort to
recognize if we can prevent an overdose death, let's do that,
but now let's not minimize everything else.
So finally, potentially a question, and maybe either
Director or Dr. Wen. This is a very complex set of problems,
and that doesn't mean that we should walk away from it, and I
could probably get into a debate with you right here about
good-faith dispensing and how that can be a benefit, and how it
will also limit access. One of the realities about over-
prescribing isn't just that the sellers, the manufacturers of
these drugs have done such a great job, now it is cheap, so
insurance companies are more than happy to make sure that that
is right there.
But if you can't get back to your physician, you are in the
hospital or in the ER and you waited 27 hours to be seen, they
need to make sure that whatever prescription they are giving
you is going to tide you over. The issue is that you have lots
of these patients who have other family members who then have
access to the excess medication, and I am struck by the number
of now large pharmacies that are thinking about making sure
that they have kiosks and opportunities for you to get rid of
those drugs safely and get them out of the hands potentially of
guests and kids and families and grandkids, which is clearly
part of the epidemic here.
Given all of these complexities, I really want to talk
about the behavioral health correlation, too, where we aren't
treating--there really isn't mental health parity. In my state,
we now have no behavioral health infrastructure, and I should
admit to you that I think that is partially the fault of this
Administration through CMS and HHS. So there is zero treatment
available. We have some of the highest heroin overdose rates.
In Mora County, it has been the highest. One in 500 is going to
die of a heroin overdose. It is huge, and it is not new. It is
decades old.
What are we doing to really create policy that recognizes
that behavioral health, that dual diagnosis and self-medicating
is really also part of this larger problem here?
Mr. Botticelli. I will start, and then I am sure that other
folks on the panel can do that. So, I think there are a number
of things from a large policy perspective that have happened.
One is the Affordable Care Act, and one of the dramatic things,
why 2 in 10 people get ----
Ms. Lujan Grisham. I am really going to just caution you.
The Affordable Care Act is the reason this Administration has
said that it was okay to cancel 100 percent of all the
behavioral health providers in my state. So in that example it
doesn't quite work, although I am a fan of general access, make
no mistake. But you should know that about New Mexico.
Mr. Botticelli. Well, I will just say that part of the
reason that people are not able to access care is the fact that
they don't have affordable coverage. We know that from data.
The Affordable Care Act says a couple of things; one, that
mental health and substance abuse disorder benefits have to be
a part of any marketplace plan. That is huge, because there has
always been a lack of coverage.
The second thing that it does, to your point, is basically
say to insurance companies you can't discriminate in the
provision of ----
Ms. Lujan Grisham. How are we enforcing that? Because I
will tell you that access is still a giant issue in my state
and so many others. So we recognize it in policy, but what are
we doing--and there are only 10 seconds left--to actually make
sure it is occurring? And given that now Medicaid is largely a
managed care environment, we are going to debate fee-for-
service and managed care ad nauseam, I am sure, in further
health care reform environments. But the reality is, if the
insurance companies aren't really making it available, then you
really don't have access in spite of coverage; correct?
Mr. Botticelli. I agree, and I should say I hear that a lot
in my travels around the country, and I think that the Federal
Government can do more work around enforcing parity, but states
can play a key role, and the state insurance commissioners can
play a pivotal role in this. Providers play a key role in
making sure that complaints get to state insurance
commissioners about this. So we all have a role to play in
terms of enforcing parity and ensuring that we are about to
finalize Medicaid managed care rules as it relates to parity.
So I would agree that we each have a role to play in terms
of parity enforcement.
Ms. Lujan Grisham. I am well above my time. Thank you, Mr.
Chairman, for your flexibility and patience.
Mr. Mica. Thank you for staying and participating.
The gentleman from South Carolina, Mr. Gowdy.
Mr. Gowdy. Thank you, Mr. Chairman.
Agent Milione--am I pronouncing that correctly?
Mr. Milione. Yes, that is correct.
Mr. Gowdy. Agent, I want to talk to you in a second about
drug court. But before we get to drug court, would you agree
that there are some who traffic in narcotics who themselves are
not users?
Mr. Milione. I would agree.
Mr. Gowdy. So drug court is not going to be much help for
us or for them because they are not addicts, they don't use. So
let's go with those who are using drugs. I think you would also
agree with me that folks who use drugs commit robberies and
burglaries and domestic violence and a host of crimes that we
consider to have an element of violence. Would you agree with
that?
Mr. Milione. Certainly, that contributes to an element of
violence, yes.
Mr. Gowdy. All right. So you have drug dealers who don't
use, and then you have drug addicts who are not engaged in
Title 21 crimes.
Mr. Milione. That is correct.
Mr. Gowdy. All right. There are different models for drug
courts. Some are diversion programs where you just divert out
of the criminal justice system altogether. Some you plead
guilty and your sentence is drug court. We had a dickens of a
time in South Carolina in getting criminal defense attorneys to
plead their clients to drug court even though in the eyes of
everyone it is better for their client, who happened to be an
addict. It is tougher than probation, so the criminal defense
attorneys had no interest in that.
So how do we devise a plan where you get drug court even if
your criminal defense attorney doesn't want you to have it?
Mr. Milione. Congressman, I don't know that I am actually
the right person to answer that since at the Federal level we
are working at a level where we are going to take in the
Federal system, and drug courts aren't an option. That would be
more the state and local level with some of our state task
forces. So I really wouldn't be in the best position to answer
that question.
Mr. Gowdy. Well, before I go to Mr. Botticelli, I want to
ask you something that might be in your wheelhouse, and that
would be diversion. Do you have a background in diversion,
Agent Milione?
Mr. Milione. Yes, yes, yes.
Mr. Gowdy. All right. Back in the old days, the standard
was if physicians prescribe drugs outside the course of a
medical practice, a professional medical practice, they
actually could be prosecuted themselves.
Mr. Milione. That is correct.
Mr. Gowdy. There was a dip, it looked like to me, in the
number of cases that DEA was pursuing from a diversion
standpoint. Was that just an optical illusion, or at some point
the DEA decided to interact more with the pharmaceutical
companies and less with the physicians who were actually
prescribing the medicine?
Mr. Milione. I need to know if you are speaking about
criminal cases. I am not aware of any dip on criminal or civil
cases. But then there is also the administrative actions,
potentially revoking the registrant's registration. I am not
aware--if you are talking about criminal, I am not aware that
there was a dip in any criminal numbers as far as the criminal
prosecutions.
Mr. Gowdy. Would you check that for me?
Mr. Milione. Be happy to.
Mr. Gowdy. All right, because ----
Mr. Milione. What span were you speaking to?
Mr. Gowdy. Well, I have been gone since 2010.
Mr. Milione. Okay.
Mr. Gowdy. I know that we did DEA diversion cases and we
prosecuted doctors, and then it just seemed to me that the
focus shifted over to pharmaceutical companies.
Mr. Milione. I can tell you from a policy perspective, and
also from what we are doing, it has never been a conscious
shift. We have aggressively gone after, where appropriate,
again a small percentage of the overall number of DEA
registrants. But I will certainly look at those numbers and get
back to you on that.
Mr. Gowdy. All right. I know it is hard to prosecute
doctors, but when you are prescribing medicine without even
doing an examination, without even so much as checking blood
pressure, you are just running a pill mill. I think, with all
due respect to my friends on the other side, prison might be
the right place for those doctors.
Mr. Botticelli, what kind of drug court can you devise
where criminal defense attorneys do not advise their clients
against their overall better health to opt for probation
instead of drug court?
Mr. Botticelli. I am not familiar with that. I would be
happy to work with you.
Mr. Gowdy. Have you met any criminal defense attorneys? Are
you familiar with them?
Mr. Botticelli. No, I am. Actually, there has been huge
support across the board as it relates to our drug courts.
Mr. Gowdy. I am sure there is, if it is a diversion court.
I am quite certain that there is huge support for that. I am
not talking about diversion where you have no record and you
actually don't face any consequences. I am talking about
pleading guilty and your punishment is drug court as opposed to
probation, with probation being much easier than drug court.
Mr. Botticelli. There are many drug courts that operate
under that model, right? So it is very interesting to me, and
again, it has gotten wide support among many folks in the
criminal justice world. So if there are particular folks you
would like us to work with in terms of doing some more
education around drug courts, what they can do with the various
models, we work very closely with the National Association of
Drug Court Professionals to do levels of training and outreach
and I would be happy to work with you.
Mr. Gowdy. I am out of time. Mr. Chairman, could I ask one
more question?
Mr. Mica. Yes.
Mr. Gowdy. Let's assume that you plead guilty to armed
robbery and your sentence is drug court. How many lapses do you
think are appropriate before the actual sentence imposed is
carried out?
Mr. Botticelli. I would have to go back and see what the
guidelines look like. I would assume that that probably gets
interpreted different ways by different judges ----
Mr. Gowdy. I was asking you.
Mr. Botticelli. I actually don't know that in terms of if
there is specific guidance around ----
Mr. Gowdy. I am talking about best practices. I mean,
obviously, for the first offense, the first relapse, it doesn't
make any sense, but the hundredth doesn't make any sense
either.
Mr. Botticelli. No. I would have to look at the National
Association of Drug Court Professionals. It does put out best
practice guidance, and I don't know explicitly what that ----
Mr. Gowdy. Would you do that for me so we can have an idea
what is fair?
Mr. Botticelli. Absolutely. But to your point, I think
there is an acknowledgement that many people with substance use
disorders do relapse, and we need to have a good response in
terms of that. You are right, people need to be held
accountable for their actions as well, so it is a real balance
between recognizing relapse and still holding people
accountable. But I would be happy to ----
Mr. Gowdy. I will tell you what I will do, then. In honor
of you, I will acknowledge that there are relapses. And in
partial honor of me, the next time you have a chance to talk to
criminal defense attorneys, you tell them that it is overall in
their clients' best interest to get off drugs, not to get onto
probation, which is much easier to navigate than drug court. In
the short term it might inure to their clients' benefit. In the
long run, it does not.
Mr. Botticelli. Okay, happy to do that.
Mr. Gowdy. Thank you.
Mr. Mica. To conclude, we will do a quick round of summary
questions.
Mr. Cummings?
Mr. Cummings. Dr. Wen, one of the things that is so
disturbing to me is there are certain areas in Baltimore where
people are getting methadone treatment, and when you see the
number of people whose lives have been destroyed, and we see
the masses of them--and I would say to the gentleman from South
Carolina, would invite you, Mr. Gowdy, I would invite you at
some point to come with me to Baltimore. When you see the
masses of people who are using, it is painfully painful, I am
telling you. I agree that there are those who are selling drugs
who are not using. I agree with you that there are folks who
are going out there and committing a lot of crime. As a matter
of fact, probably most of the crime in Baltimore has something
to do with drugs in one way or another.
But there is also a group of people who are truly addicted,
and they are dying at 78 a day. That is major stuff. So I would
invite you. I think when you see it like that--because the
Chairman came with me to Baltimore and saw what I am talking
about. In some kind of way, we have to get to that, and I think
there are a lot of different remedies to try to address these
things, but I am definitely not one that wants to be soft on
people who are going around and selling death, and I have said
that many times. But at the same time, we have a lot of people
who truly are addicted.
Dr. Wen, where do you--and the gentleman from South
Carolina made some good points--where do you draw the line and
say, okay, I have these addicts, but these addicts, some of
them are committing crimes. And what do you think of the
methadone treatment? Because a lot of people question whether
you are just keeping people continuing to be addicted to a
substance. Do you follow me?
Dr. Wen. Thank you very much, Congressman Cummings. So the
first issue is that we know in Baltimore that there are 20,000
people who use heroin, and many more who are addicted to other
drugs, and most of the drug arrests that are happening--there
are 73,000 arrests that happen in our city every year. The
majority of the arrests that happen are for individuals for
only selling drugs to feed their own habit.
What they need is not incarceration. What they need is drug
treatment, and that is what we have to provide, and we have to
make sure they get treatment while they are incarcerated. If
they are incarcerated, they have to get treatment in jail as
well.
Mr. Cummings. Can you pause there for one second? One thing
a lot of people don't know about heroin is you can be addicted
to heroin for 30 or 40 years. Am I right?
Dr. Wen. Yes.
Mr. Cummings. And still function. Is that right?
Dr. Wen. Yes. There are some individuals who are very high
functioning who are in all walks of life, all professions,
while they are addicted to a variety of drugs, including
alcohol as well.
To your point about treatment, I am a doctor and a
scientist and I have to use the evidence, and evidence shows
that medication-assisted treatment, including methadone and
buprenorphine, are the first line, they are the standard of
care when it comes to opioid addiction. We also agree, though,
that we need to have increased treatment, including with
buprenorphine, which can be given in an office-based setting.
That will also help us to reduce the stigma around addiction.
And, Congressman Cummings, I want to thank you also for
your leadership in Baltimore City. We hope that there will be
additional funding directed to our cities of greatest need,
areas of greatest need. We are the ones on the front lines, we
are the ones who are innovating, and we are the ones who need
the most resources, rather than have the peanut butter spread
evenly across all areas.
Mr. Cummings. You know, naloxone, the idea that we were
getting a 10-pack for $190 back in 2014, and then they
increased it to $400--is that right?--have you seen any
movement? I know that various states and our attorney general
has been trying to work out something where we can get that
cost back down. Have you seen any movement in that area?
Dr. Wen. We have not. We have not in Baltimore City. Last
year we were fortunate to receive a generous donation from a
pharmaceutical company to assist us for over 8,000 units of
naloxone, but we can't depend forever on the generosity, on the
donations from companies. We have to have this medication,
which is a generic medication that is on the World Health
Organization's list of essential medications, available to
everyone so that we can save lives.
Mr. Cummings. Again, I want to thank all of you for being
here today. We do have a lot to do. It is a very serious
problem, and we are going to have to try to hit it from a lot
of angles. As Chairman Mica said, years ago he and I--you were
the Chairman--the chairman and ranking member of a subcommittee
called the Drug Subcommittee did a lot of work, and we are
going to have to do even more. So, I thank all of you.
Mr. Mica. Let's see. Mr. Grothman?
Mr. Grothman. Sure. I will give you two quick questions.
First of all, drunk driving is a big problem in our
society, and when we arrest somebody for drunk driving, some
people are alcoholics and have an addiction to alcohol, and a
lot of people are just irresponsible people, social pressure,
whatever, got a drunk driving ticket. I have only met two
people in my life who have used heroin. They both were in the
criminal justice system. Both felt they were not addicted.
Percentage-wise, give me a stab at it. Of the people who
are arrested with heroin possession or whatever, what
percentage are addicts, and what percentage are just people who
are social pressure or whatever, want to feel good for the day,
are using heroin? What percentage do you think need treatment,
and what percentage are people who are just like the person who
gets a drunk driving ticket because they are just
irresponsible? Could a couple of you give me your guess?
Mr. Botticelli. I will take a stab at it and take a look at
it. I would assume that the rates of non-addictive heroin use
are incredibly low just because it is a very powerfully
addictive drug.
Mr. Grothman. Each one of you just give me a percentage. I
don't have a lot of time. What percentage of people who are
arrested for heroin are like the two people that I talked to
who didn't crave it, didn't need it, one did it for social
reasons and one was going through a depression at that time?
What percentage are addicted and what percentage are just using
it because my buddy is using it and it is cool?
Mr. Botticelli. I would say probably 5 percent of people
who are using marijuana have no addiction to it, but that would
be ----
Mr. Grothman. You mean heroin?
Mr. Botticelli. Heroin. I am sorry.
Mr. Grothman. Only 5 percent are addicted.
The next gentleman?
Mr. Milione. I can't give you a percentage. That is not how
we encounter--we don't encounter individuals that way based on
the work that we do at the DEA. So I can't give you a
percentage.
Mr. Grothman. Okay. Ms. Enomoto?
Ms. Enomoto. What we can give you is data from our National
Survey on Drug Use and Health, which just surveys people about
how many people have used heroin the last month or in the last
year, and then how many of those people actually meet criteria
for disorder, and I would imagine you would find fairly
parallel realities. We don't do screening on arrest. We don't
have the time to do diagnostic evaluations on everyone who is
arrested for possession, so we don't have those data available.
Mr. Grothman. Do you have an opinion?
Ms. Enomoto. No, but I am happy to get you those data, the
data that we do have.
Mr. Grothman. Anybody up there have an opinion? Anyone else
have an opinion on the percentage that are addicted and the
percentage that are just using?
Dr. Wen. I can give you my perspective as a practicing
physician, and also experience in Baltimore, which is that the
vast majority--we are talking well over 90 percent--will be
individuals who have an addiction. Heroin comes from opium, and
it is one of the most addictive substances in the world.
Mr. Grothman. Okay.
Ms. Jacobs. I don't have the answer. I can tell you that
out of the 2,000 people that come through our jail that
acknowledge they are using heroin, all of them have an
addiction. Now, the reality is that they are acknowledging it
because they know they are going to go through withdrawal.
But, you know, I think that there is some information that
we could obtain through some databases dealing with people that
have been prescribed opioids and how many of them have become
addicted. I don't really think ----
Mr. Grothman. I am out of time. I will cut you off because
I want to ask one more question.
Okay, so maybe the two people I have met who have actually
used heroin and got caught, when they say they were not craving
it at all, maybe they are an aberration.
Okay, the next question I have, just one example. If I
break my arm, just a simple break, do you think under any
circumstances, given that they never prescribed it 15 years
ago, under any circumstances--what percentage of the time do
you think a doctor should prescribe opiates for a broken arm?
Dr. Wen. A broken arm is extremely painful, and if somebody
had come to the ER with a broken arm, I would give them even IV
medications, including for opioids. So it does make sense that
this is a reasonable use for opioids.
Mr. Grothman. Does anybody else think in all cases for a
broken arm you should be prescribing opiates? For how long? Say
for over a week? What percent think if you have a broken arm
you should prescribe opiates, give a prescription for at least
a week?
Mr. Botticelli. I can tell you what the CDC guidelines
recommend in those kinds of situations. Obviously, that is a
decision that needs to be made between the patient and the
doctor. There should be a conversation to do it. But the CDC
guidelines say the lowest possible dose and the shortest
possible duration.
Mr. Grothman. So would you, if you were the doctor, give a
prescription for at least a week?
You know, politicians are known for not giving straight
answers, not you guys. But okay, go ahead.
Anybody else have a stab at this? Is it responsible to give
a prescription for opiates for at least a week if I crack my
arm here?
Ms. Jacobs. Sir, if I could take a stab at this?
Mr. Grothman. Sure.
Ms. Jacobs. I am not a doctor. I am a mother of four
children. One of my children has had multiple broken bones in
sports. One of them had three torn ACLs and meniscus tears, so
they have all gone through a lot of surgery. Each time they
have been given opioids, and each time I would say it was
probably for about a week. In all cases they were warned--I was
warned about what to look for in case of addiction. In every
case, they were not on opioids for more than 48 hours. We took
them off in 48 hours. So I can tell you that as severe as those
injuries were, we weaned them off.
I had a severely broken bone in both of my arms. I was off
of painkillers in three days and never on opioids. So I hope
that answers your question. I think anything more than that
really needs to be carefully looked at.
Mr. Grothman. Now, are you a mental health professional?
I'm sorry, are you a health professional?
Ms. Jacobs. Am I? No. I am a mom of four kids. I think I
probably know a whole lot of things.
Mr. Grothman. No wonder you have so much common sense.
Ms. Jacobs. I could be a mental health professional by the
time I raise four children.
Mr. Grothman. Good. We got one commonsense answer out of
the five, and it was the person who is not a mental health
professional--not a health professional.
Thank you very much.
Mr. Mica. I thank the gentleman.
Mr. Gowdy?
Mr. Gowdy. Thank you, Mr. Chairman.
I want to thank all of our panelists, and I want to thank
my friend from Maryland for his gracious invitation, which I
will take him up on. I would love to go see what is happening
in Baltimore. I expect, Mr. Chairman, that it is, at least on a
larger scale, similar to what was happening in my own home
town, which is why I started a drug court in 2000, and in
addition to that drug court we started a drug court for
expectant mothers who were using controlled substances during
the course of their pregnancy, because I do believe getting
them off drugs is infinitely preferable to incarceration in
non-violent cases.
I would also say this, Mr. Chairman, and to my friend from
Maryland, there is no joy like going to a graduation ceremony
for those who have concluded drug court successfully. I have
had folks that I prosecuted stop me in the grocery store to
show me the certificate from their graduation, and they were
prouder of that than anything you or I could have ever
accomplished in our careers. I used to counsel folks who were
still going to need prison, so I would be a little reluctant to
close all the prisons as we open up drug courts.
But the gentleman from Maryland is right. I would say about
half the crime we saw for 16 years, drugs and/or alcohol were
at the root of that. There was one addict in particular, Mr.
Chairman, who took a hammer to the older couple that lived next
to him and beat them. They were in bed, asleep, in the middle
of the night, and he broke in to rob them, and he beat them
with a hammer where they were unrecognizable as humans. That
was the pathologist's description, not mine. And then he raped
the female victim post-mortem. He was an addict.
But we are going to need to hang onto those prisons, Mr.
Chairman, in addition to the drug courts, and I would be happy
to go to Maryland with my friend to see the work that they are
doing there, and I would invite him down to Spartanburg.
Drug courts can save people's lives and get them off. I
just hope they get off before they do acts of violence against
the innocent public, because the addicts sometimes leave a wake
of violence and mayhem in the wake of their addiction.
With that, I would yield back.
Mr. Cummings. Would the gentleman yield, please, just for
one second?
Mr. Gowdy. Be happy to.
Mr. Cummings. First of all, I want to thank you for
agreeing to come to Baltimore. I agree to go to South Carolina,
be happy to.
Just one thing, Mr. Chairman. I agree with you, we have
very effective drug courts in Maryland, and I know what you are
talking about. One of my first cases was a death penalty case,
early in my career, where a young man hammered his grandmother
to death, and he was on drugs. So I get it, I get it.
Like I said, I think there are different categories here of
folks, and I swear, I just wish we could catch them early, like
you said, because I have seen some really bad, bad stuff. So
the thing is trying to figure out a balance here. And even when
you figure out the balance, you are probably going to still
find people falling through the cracks, but I guess we have to
use our best science and best judgment.
But I thank the gentleman for yielding.
Mr. Gowdy. Yes, sir.
Mr. Mica. I thank the members for participating, and our
witnesses.
I just have a couple of final things.
It is now 1 o'clock. We started this some three hours ago.
Fifteen people in the United States have died from drug
overdoses, three of them from heroin. Before the day is over,
120 Americans will die, 24 of them from heroin.
We have heard different things touted here today. Some
people have said we just need to put more money into treatment.
Treatment is essential, but treatment is at the end of the
line.
You heard a couple of comments from the other side of the
aisle today that we need to act before we go home at Easter and
put more money into the heroin and drug overdose situation.
This is the remarks of Senator Grassley on the floor.
``According to the Office of National Drug Control Policy, the
appropriations act passed in December provided more than $400
million in funding specifically to address the opioid epidemic.
This is an increase of $100 million over the previous year.''
That is a 25 percent increase, okay? None of that money, when
he said that just a few months ago, has been spent yet. All of
that money is available today. Is that right? Or most of it?
Tell me. Most of that money is available today, and you would
think we were going out of here not providing money--25 percent
increase.
I want this in the record, and then let's put in the record
too the record of how much was asked for, how much was
appropriated, how much money was taken from interdiction and
law enforcement and put into treatment, okay? These are just
the facts. We don't want to deal with the facts, but we are
going to put this also in the record so you can see that,
again, there is money there.
And I want a report. I want a report, I am telling you,
this week, of how much money is spent, and I want that in the
record, okay Mr. Botticelli? And then I want something from
you, too, Ms. Director of our Mental Health and Substance Abuse
office. I want to see how much money is pending, and I want it
in the record, and I want it in my office by Friday close of
business, because I know the money is there. It hasn't even
been distributed.
So we are not going to play these games. I want the facts
there, and we need to stop this stuff at our border. It is
coming in, and I just showed--my mayor I think also cited it.
It is coming in by the boatload across the borders.
I have one question, too. I talked about El Chapo. The
biggest drugs are coming across the border like it was some
kind of a vacation holiday. I was told, speaking of weapons
which are used in most drug offenses, most of the murders are--
in Baltimore, they are killing people in drugs. In Orlando, we
are killing them--we kill them at the mall, we kill them in our
streets, in our great communities, our poor communities. We are
killing them. Most of them are gun deaths, and they are related
to drug trafficking, aren't they, Mr. Milione?
Mr. Milione. Yes ----
Mr. Mica. Yes, and a lot of those are illegal weapons. Now
I am told--I just got this this morning--El Chapo, who is
coming back and forth, also one of the weapons he had was
traced to the Fast and Furious. So it was a weapon that was
supplied by the United States Government, and the principal
drug trafficker who is trafficking across the border like a
holiday visit, he had one of the Fast and Furious. Are you
aware of that?
Mr. Milione. I am aware from the press reports.
Mr. Mica. Okay. Can you confirm that also for the
committee?
Mr. Milione. I wouldn't be in the best position to do that.
It would be another agency. I will take it back to the
Department.
Mr. Mica. All right. Well, I want you to check on it for me
and let me know, okay?
And I am very pleased with the people out there, but I met
with some of your people, and the prosecutions are not what
they should be. You know, you go to Singapore and they do not
have a treatment program. I want to put you out of business,
Ms. Wen, all the treatment programs. I want to put them out of
business because our kids and our adults should not have to go
to treatment. But we are allowing this crap to come into the
United States. It is offensive.
We are killing tens of thousands, folks, and anything else,
people would be outraged. Where are you? Just Say No, and
saying Just Say Maybe, there are consequences, or Just Say Okay
makes a difference to our young people and what is happening.
You can tell I can get a little hot, the Italian comes out
of me, but I have seen them. I have seen them dying in the
streets of Baltimore, and I see them now dying again in my
community, and we need to do something about it, and that
supply has to be cut off. Then I can put Ms. Wen and others out
of business. We won't have to be treating people. We won't have
the scourge on our streets.
There being no further business before this committee of
the House, this hearing is adjourned.
Thank you, witnesses.
[Whereupon, at 1:10 p.m., the committee was adjourned.]
APPENDIX
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