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

                       EXAMINING THE GROWING PROBLEMS OF
        PRESCRIPTION DRUG AND HEROIN ABUSE: STATE AND LOCAL PERSPECTIVES

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

                                    HEARING

                                   BEFORE THE

                  SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

                                     OF THE

                        COMMITTEE ON ENERGY AND COMMERCE
                           HOUSE OF REPRESEN7TATIVES

                        ONE HUNDRED FOURTEENTH CONGRESS

                                 FIRST SESSION

                                   __________

                                 MARCH 26, 2015

                                   __________

                               Serial No. 114-27

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

          Printed for the use of the Committee on Energy and Commerce

                            energycommerce.house.gov

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                        COMMITTEE ON ENERGY AND COMMERCE

                              FRED UPTON, Michigan
                                     Chairman
    JOE BARTON, Texas                    FRANK PALLONE, Jr., New Jersey
      Chairman Emeritus                    Ranking Member
    ED WHITFIELD, Kentucky               BOBBY L. RUSH, Illinois
    JOHN SHIMKUS, Illinois               ANNA G. ESHOO, California
    JOSEPH R. PITTS, Pennsylvania        ELIOT L. ENGEL, New York
    GREG WALDEN, Oregon                  GENE GREEN, Texas
    TIM MURPHY, Pennsylvania             DIANA DeGETTE, Colorado
    MICHAEL C. BURGESS, Texas            LOIS CAPPS, California
    MARSHA BLACKBURN, Tennessee          MICHAEL F. DOYLE, Pennsylvania
      Vice Chairman                      JANICE D. SCHAKOWSKY, Illinois
    STEVE SCALISE, Louisiana             G.K. BUTTERFIELD, North Carolina
    ROBERT E. LATTA, Ohio                DORIS O. MATSUI, California
    CATHY McMORRIS RODGERS, Washington   KATHY CASTOR, Florida
    GREGG HARPER, Mississippi            JOHN P. SARBANES, Maryland
    LEONARD LANCE, New Jersey            JERRY McNERNEY, California
    BRETT GUTHRIE, Kentucky              PETER WELCH, Vermont
    PETE OLSON, Texas                    BEN RAY LUJAN, New Mexico
    DAVID B. McKINLEY, West Virginia     PAUL TONKO, New York
    MIKE POMPEO, Kansas                  JOHN A. YARMUTH, Kentucky
    ADAM KINZINGER, Illinois             YVETTE D. CLARKE, New York
    H. MORGAN GRIFFITH, Virginia         DAVID LOEBSACK, Iowa
    GUS M. BILIRAKIS, Florida            KURT SCHRADER, Oregon
    BILL JOHNSON, Ohio                   JOSEPH P. KENNEDY, III,
    BILLY LONG, Missouri                     Massachusetts
    RENEE L. ELLMERS, North Carolina     TONY CARDENAS, California
    LARRY BUCSHON, Indiana
    BILL FLORES, Texas
    SUSAN W. BROOKS, Indiana
    MARKWAYNE MULLIN, Oklahoma
    RICHARD HUDSON, North Carolina
    CHRIS COLLINS, New York
    KEVIN CRAMER, North Dakota

                  Subcommittee on Oversight and Investigations

                            TIM MURPHY, Pennsylvania
                                     Chairman
    DAVID B. McKINLEY, West Virginia     DIANA DeGETTE, Colorado
      Vice Chairman                        Ranking Member
    MICHAEL C. BURGESS, Texas            JANICE D. SCHAKOWSKY, Illinois
    MARSHA BLACKBURN, Tennessee          KATHY CASTOR, Florida
    H. MORGAN GRIFFITH, Virginia         PAUL TONKO, New York
    LARRY BUCSHON, Indiana               JOHN A. YARMUTH, Kentucky
    BILL FLORES, Texas                   YVETTE D. CLARKE, New York
    SUSAN W. BROOKS, Indiana             JOSEPH P. KENNEDY, III,
    MARKWAYNE MULLIN, Oklahoma               Massachusetts
    RICHARD HUDSON, North Carolina       GENE GREEN, Texas
    CHRIS COLLINS, New York              PETER WELCH, Vermont
    KEVIN CRAMER, North Dakota           FRANK PALLONE, Jr., New Jersey (ex
    JOE BARTON, Texas                        officio)
    FRED UPTON, Michigan (ex officio)

                                 C O N T E N T S

                                  ----------
                                                                       Page
    Hon. Tim Murphy, a Representative in Congress from the
      Commonwealth of Pennsylvania, opening statement................     1
        Prepared statement...........................................     4
    Hon. Diana DeGette, a Representative in Congress from the state
      of Colorado, opening statement.................................     6
    Hon. Fred Upton, a Representative in Congress from the State of
      Michigan, opening statement....................................     8
        Prepared statement...........................................     9
    Hon. Joseph P. Kennedy, III, a Representative in Congress from
      the Commonwealth of Massachusetts, opening statement...........    10
    Hon. Frank Pallone, Jr., a Representative in Congress from the
      State of New Jersey, prepared statement........................   101

                                   Witnesses

    Fred Wells Brason, II, Executive Director, Project Lazarus,
      Moravian Falls, North Carolina.................................    12
        Prepared statement...........................................    15
    Sarah T. Melton, PharmD, BCPP, BCACP, CGP, FASCP, Associate
      Director of Pharmacy Practice, Gatton College of Pharmacy at
      East Tennessee State University, Johnson City, Tennessee, and
      Chair of the Board of Directors of Onecare of Southwest
      Virginia, Bristol, Virginia....................................    25
        Prepared statement...........................................    28
        Answers to submitted questions...............................   111
    Stefan R. Maxwell, M.D., Associate Professor, Pediatrics, WVU
      School of Medicine, MEDNAX Medical Group, Medical Director,
      NICU, Women and Children's Hospital, Charleston, West Virginia.    38
        Prepared statement...........................................    40
        Answers to submitted questions...............................   115
    Rachelle Gardner, Chief Operating Officer, Hope Academy,
      Indianapolis, Indiana..........................................    49
        Prepared statement...........................................    52
    Victor Fitz, Cass County, Michigan, Prosecutor, and President of
      the Prosecuting Attorneys Association of Michigan (PAAM),
      Cassopolis, Michigan...........................................    54
        Prepared statement...........................................    56
    Michael Griffin, Narcotics Unit Supervisor--K9 Handler, Special
      Investigations Division, Tulsa Police Department, Tulsa,
      Oklahoma.......................................................    67
        Prepared statement...........................................    69
    Caleb Banta-Green, Senior Research Scientist, Alcohol and Drug
      Abuse Institute, University of Washington, Seattle, Washington.    80
        Prepared statement...........................................    82
        Answers to submitted questions...............................   119

                               Submitted Material

    Majority memorandum..............................................   103
    Article entitled, ``The New Heroin Epidemic,'' in The Atlantic,
      October 30, 2014, submitted by Mr. Tonko \1\
    U.S. Department of Justice announcement, submitted by Ms. DeGette
      \2\

    ----------
    \1\ Available at: http://docs.house.gov/meetings/if/if02/
      20150326/103254/hhrg-114-if02-20150326-sd008.pdf.
    \2\ Available at:http://docs.house.gov/meetings/IF/IF02/20150326/
      103254/HHRG-114-IF02-20150326-SD007.pdf

     EXAMINING THE GROWING PROBLEMS OF PRESCRIPTION DRUG AND HEROIN ABUSE:
                          STATE AND LOCAL PERSPECTIVES

                                  ----------

                            THURSDAY, MARCH 26, 2015

                      House of Representatives,
          Subcommittee on Oversight and Investigations,
                              Committee on Energy and Commerce,
                                                        Washington, DC.
        The subcommittee met, pursuant to call, at 10:15 a.m., in
    room 2123 of the Rayburn House Office Building, Hon. Tim Murphy
    (chairman of the subcommittee) presiding.
        Present: Representatives Murphy, McKinley, Griffith,
    Bucshon, Brooks, Mullin, Hudson, Collins, Upton (ex officio),
    DeGette, Schakowsky, Tonko, and Kennedy.
        Staff present: Sean Bonyun, Communications Director;
    Leighton Brown, Press Assistant; Noelle Clemente, Press
    Secretary; Brittany Havens, Legislative Clerk; Charles
    Ingebretson, Chief Counsel, Oversight and Investigations; Chris
    Santini, Policy Coordinator, Oversight and Investigations; Alan
    Slobodin, Deputy Chief Counsel, Oversight; Sam Spector,
    Counsel, Oversight; Jeff Carroll, Democratic Staff Director;
    Chris Knauer, Democratic Oversight Staff Director; Una Lee,
    Democratic Chief Oversight Counsel; Elizabeth Letter,
    Democratic Professional Staff Member; and Tim Robinson,
    Democratic Chief Counsel.

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

        Mr. Murphy. Good morning.
        As I call to order this Oversight and Investigations
    Subcommittee hearing to examine the growing problem of
    prescription drug and heroin abuse, allow me to share a few
    quotes from an article in the New York Times, citing the views
    of Dr. Hamilton Wright of Ohio. In the article, Dr. Wright is
    quoted as saying: ``Of all the nations of the world, America
    consumes the most opium, in one form or another. The habit has
    this Nation in its grip to an astonishing extent. Our prisons
    and our hospitals are full of victims of it, it has robbed ten
    thousand business men and women of sense. The drug habit has
    spread throughout America until it threatens us with very
    serious disaster.''
        What is striking about these statements is not the dismal
    picture they paint, but rather, that these remarks were
    published over 100 years ago in 1911. Back then, of course, we
    did not have the scientific or government involvement that we
    have today. Back then, there was no National Office of Drug
    Control Policy--the ONDCP--and there was no Department of
    Health and Human Services, no Substance Abuse and Mental Health
    Services Administration, and there was no National Institute on
    Drug Abuse. Yet despite all of our science and public health
    agencies, and despite the billions of federal dollars devoted
    to fighting the opioid problem, the situation is no better than
    it was 100 year ago. Indeed, many would say the situation is
    far worse.
        According to the Centers for Disease Control, in just the
    past 3 years alone, the number of heroin overdose deaths in the
    United States has tripled. Tripled. And in some parts of the
    country, such as the Midwest, heroin overdose death rates have
    increased over 900 percent. Every day 120 people die from a
    drug overdose. The vast majority of these overdose deaths are
    due to prescription opioid medications. That is more than
    43,000 deaths last year, or the tragic equivalent of one
    jetliner going down every single day.
        In 2009, an estimated 13,000 babies were born in the United
    States addicted to heroin or prescription opioids. That is
    about one opioid-addicted baby every hour of the day, every day
    of the week. Please note that this statistic is from 2009,
    several years before the CDC announced our country was in the
    midst of an overdose epidemic and before the current explosion
    of heroin overdose deaths. The number of babies born addicted
    to opioids is much worse today. I used to work in a newborn
    intensive care unit, and I have watched too many tiny infants
    go through withdrawal symptoms. But seeing only one is enough
    to break your heart.
        Something is desperately wrong with our Nation's response
    to the opioid epidemic, and it is quite literally a matter of
    life and death that we get honest answers and not remain
    misguided in our approach to how we solve this crisis.
        Every Member of Congress is seeing the consequence of the
    federal government's failure because it touches every community
    and every family across America. My own district in
    Pennsylvania has seen the terrible consequences of addiction
    and death from opiate overdoses, and the problem has only
    gotten worse over the past year. In Westmoreland County,
    Pennsylvania, the drug overdose death total for 2014 surpassed
    that of 2013--a record to that point--by an additional death,
    and during that time, the number of accidental deaths caused by
    heroin in the county increased by over 30 percent. In 2014,
    Allegheny County, where Pittsburgh is, had 281 fatal overdoses
    reported, compared to 278 the previous year, and it is climbing
    for this year.
        No federal agency has a more central role in this ongoing
    epidemic than the Department of Health and Human Services. HHS
    and its Substance Abuse and Mental Health Services
    Administration, otherwise known as SAMHSA, are tasked with
    leading our Nation's public health response to opioid and
    heroin abuse and addiction. SAMHSA regulates our country's
    1,300 opioid maintenance--formerly known as methadone clinics--
    and is responsible for certifying the 26,000 physicians who
    prescribe the semi-synthetic opioid buprenorphine. According to
    testimony provided by SAMHSA before this subcommittee in April
    of last year, nearly 1.5 million people were ``treated''--and I
    put ``treated'' in quotes--with these opioids in 2012. That is
    a five-fold increase in the last 10 years. Now, I might add, I
    will not call this treatment. It is addiction maintenance.
        Buprenorphine can more safely maintain a person's
    dependence by reducing the need for illegal opioid abuse, such
    as heroin, and thereby the risk for overdose. But make no
    mistake, buprenorphine is a highly potent opioid, which
    according to SAMHSA, is 20 to 50 times more potent than
    morphine. So it is worth considering that our national strategy
    to combat substance abuse is to maintain addiction by either
    prescribing or administering a heroin-replacement opioid. When
    you consider research from the National Institute on Drug Abuse
    documenting that almost everyone who stops taking buprenorphine
    relapses to illicit opioid use within a matter of weeks, it is
    deeply concerning thatwe don't have the best solutions for
    addiction recovery. According to the Drug Enforcement
    Administration, when police conduct a prescription drug bust,
    the third most frequently seized drug by law enforcement is
    buprenorphine--more than methadone, more than morphine, more
    than codeine. And unlike clinics that administer methadone,
    there are no requirements for buprenorphine clinics to offer or
    even discuss non-addictive treatment alternatives with
    patients, no requirements to develop treatment plans, no
    requirements to protect the public against it being diverted
    for illicit use. Meanwhile, the CDC reports that buprenorphine
    is the most frequently cited prescription drug in poisonings of
    children, accounting for nearly 30 percent of all opioid-
    related emergency department visits and 60 percent of emergent
    hospitalizations among children.
        Worse yet, of opioid-addicted babies who start their
    fragile lives being medically detoxified off of opioids, nearly
    half of their mothers are on buprenorphine or methadone
    maintenance in HHS/SAMHSA-regulated or -certified practices.
        This is government-supported addiction. It is not moving
    people to sobriety. We should not just focus on the
    extraordinary costs of detoxifying babies off of buprenorphine,
    but also the profound consequences for these babies whose
    entire experience in the womb and after they are born is
    dominated by buprenorphine dependence. Further, there are
    significant concerns about short- and long-term
    neurodevelopmental impacts of opioid exposure in utero. Why is
    the government subsidizing this harm?
        Despite these problems, HHS and SAMHSA continue to actively
    and aggressively promote the use of buprenorphine, yet
    noticeably silent on promoting research and innovative measures
    with the goal of ending opioid addiction, not simply continuing
    addiction through drug maintenance programs of methadone. It
    concerns me that HHS and SAMHSA have no practical guidance on
    how to get people off of this prescribed opioid when those on
    buprenorphine maintenance for substance abuse disorders use
    illicit opioids an average of four times a week.
        Now, I recognize this morning that HHS announced new plans
    and funding to work on this issue, and this committee eagerly
    awaits to see the details on how that will play out.
        Compounding this crisis is the lack of evidence-based
    treatment to end opioid addiction, not merely replace an
    illicit drug with a government-sanctioned one. Evidence-based
    treatment includes decisions based on scientific studies with
    quantitative data, and is distinguished from those relying on
    anecdotes and subjective observations.
        Only about 10 percent of persons with a substance abuse
    disorder will get any form of medical care. Of those who are
    lucky enough to get care, only 10 percent of them will get
    evidence-based treatment for the disease of addiction. Yet most
    medical professionals are not sufficiently trained to diagnose
    or treat the disease of addiction, and most providing addiction
    care are not medical professionals and are not equipped to
    provide the full range of effective treatments.
        Now, I believe in recovery. I believe in lives being
    restored and every individual living up to their full God-given
    potential and doing so drug-free. I desperately want our
    federal efforts to work in every community and for every family
    that seeks care for addiction disorders. And I know that
    working together, at the federal, State, and local level, we
    will achieve success. But we have to set our eyes on the goal
    of full recovery, not just addiction maintenance. We can do
    this, I have no doubt.
        We continue our oversight series today by listening to law
    enforcement and public health officials who are working at the
    on the front lines to protect our communities and our families
    in this national epidemic. We are grateful for your service and
    for taking the time to be with us today.
        [The prepared statement of Mr. Murphy follows:]

                     Prepared statement of Hon. Tim Murphy

        Good morning. As I call to order this Oversight &
    Investigations Subcommittee hearing to examine the growing
    problem of prescription drug and heroin abuse, allow me to
    share a few quotes from an article in the New York Times,
    citing the views of a Dr. Hamilton Wright, of Ohio. In the
    article, Dr. Wright is quoted as saying: ``Of all the nations
    of the world, America consumes the most opium, in one form or
    another.''
        ``The habit has this Nation in its grip to an astonishing
    extent. Our prisons and our hospitals are full of victims of
    it, it has robbed ten thousand business men [and women] of
    sense ....''
        ``The drug habit has spread throughout America until it
    threatens us with very serious disaster.'' What is striking
    about these statements is not the dismal picture they paint,
    but rather, that these remarks were published over 100 years
    ago in 1911.
        Back then, of course, we did not have the scientific or
    government involvement that we have today. Back then, there was
    no National Office of Drug Control Policy (ONDCP); there was no
    Department of Health and Human Services (HHS), no Substance
    Abuse and Mental Health Services Administration (SAMHSA); and
    there was no National Institute on Drug Abuse (NIDA). Yet
    despite all of our science and public health agencies, and
    despite the billions of federal dollars devoted to fighting the
    opioid problem, the situation is no better than it was 100 year
    ago. Indeed, the situation is much worse.
        According to the Centers for Disease Control (CDC) in just
    the past three years alone, the number of heroin overdose
    deaths in the United States has tripled. And in some parts of
    the country, such as the Midwest, heroin overdose death rates
    have increased over 900 percent.
        Everyday 120 people die from a drug overdose. The vast
    majority of these overdose deaths are due to prescription
    opioid medications. That's more than 43,000 deaths last year,
    or the equivalent of one jetliner going down every single day.
        In 2009, an estimated 13,000 babies were born in the United
    States addicted to heroin or prescription opioids. That's about
    one opioid-addicted baby every hour of the day, every day of
    the week. Please note that this statistic is from 2009, several
    years before the CDC announced our country was in the midst of
    an overdose epidemic and before the current explosion of heroin
    overdose deaths. The number of babies born addicted to opioids
    is much worse today. I used to work on a newborn intensive care
    unit. I've watched too many tiny infants go through withdrawal
    symptoms. But seeing only one is enough is to break your heart.
        Something is desperately wrong with our nation's response
    to the opioid epidemic, and it is quite literally a matter of
    life and death that we get honest answers and not remain
    misguided in our approach to how we solve this crisis.
        Every member of Congress is seeing the consequence of the
    federal government's failure because it touches every
    community; every family across America. My own district has
    seen the terrible consequences of addiction and death from
    opiate overdoses, and the problem has only gotten worse over
    the past year. In Westmoreland County, Pennsylvania, the drug
    overdose death total for 2014 surpassed that of 2013--a record
    to that point--by one additional death. During the same time,
    the number of accidental deaths caused by heroin in the county
    increased by over 30 percent. In 2014, Allegheny County had 281
    fatal overdoses reported, compared to 278 the previous year.
        No federal agency has a more central role in this ongoing
    epidemic than the Department of Health and Human Services. HHS
    and its Substance Abuse and Mental Health Services
    Administration (SAMHSA) are tasked with leading our nation's
    public health response to opioid and heroin abuse and
    addiction. SAMHSA regulates our country's 1,300 opioid
    maintenance (formerly known as methadone clinics), and is
    responsible for certifying the 26,000 physicians who prescribe
    the semi-synthetic opioid buprenorphine. According to testimony
    provided by SAMHSA before this Subcommittee in April of last
    year, nearly 1.5 million people were ``treated'' with these
    opioids in 2012. That is a 5-fold increase in the last ten
    years. I do not call this ``treatment.'' It is addiction
    maintenance.
        Buprenorphine can more safely maintain a person's
    dependence by reducing the need for illegal opioid use, such as
    heroin, and thereby the risk for overdose. But make no mistake,
    buprenorphine is a highly potent opioid, which according to
    SAMHSA, is ``20-50 times more potent than morphine.'' So it is
    worth considering that our national strategy to combat
    substance abuse is to maintain addiction by either prescribing
    or administering a heroin-replacement opioid. When you consider
    research from the National Institute on Drug Abuse documenting
    that almost everyone who stops taking buprenorphine relapses to
    illicit opioid use within a matter of weeks, it is deeply
    concerning we don't have the best solutions for addiction
    recovery.
        According to the Drug Enforcement Administration, when
    police conduct a prescription drug bust, the 3rd most
    frequently seized drug by law enforcement is buprenorphine.
    More than methadone. More than morphine. More than codeine. And
    unlike clinics that administer methadone, there are no
    requirements for buprenorphine clinics to offer or even discuss
    non-addictive treatment alternatives with patients. No
    requirement to develop treatment plans. No requirements to
    protect the public against buprenorphine being diverted for
    illicit use.
        Meanwhile, the CDC reports that buprenorphine is the most
    frequently cited prescription drug in poisonings of children,
    accounting for nearly 30% of all opioid-related emergency
    department visits and 60% of emergent hospitalizations among
    children.
        Worse yet, of opioid-addicted babies who start their
    fragile lives being medically detoxified off of opioids, nearly
    half of their mothers are on buprenorphine or methadone
    maintenance in HHS/SAMHSA regulated or certified practices.
    This is government-supported addiction. It is not moving people
    to sobriety. We should not just focus on the extraordinary
    costs of detoxifying babies off of buprenorphine, but also, the
    profound consequences for these babies whose entire experience
    in the womb and after they are born is dominated by
    buprenorphine dependence. Further, there are significant
    concerns about short and long term neurodevelopmental impacts
    of opioid exposure in utero. Why is the government subsidizing
    this harm?
        Despite these problems, HHS and SAMHSA continue to actively
    and aggressively promote the use of buprenorphine, yet
    noticeably silent on promoting research and innovative measures
    with the goal of ending opioid addiction, not simply continuing
    addiction through drug maintenance programs of methadone or
    buprenorphine. It concerns me that HHS and SAMHSA have no
    practical guidance on how to get people off of this prescribed
    opioid when those on buprenorphine maintenance for substance
    abuse disorders use illicit opioids an average of four times a
    week.
        Compounding this crisis is the lack of evidence-based
    treatment to end opioid addiction, not merely replace an
    illicit drug with a government sanctioned one. Evidence-based
    treatment includes decisions based on scientific studies with
    quantitative data, and is distinguished from those relying on
    anecdotes and subjective observations. Only about 10 percent of
    persons with a substance abuse disorder will get any form of
    medical care; of those who are lucky enough to get care, only
    10 percent of them will get evidence-based treatment for the
    disease of addiction. Yet, most medical professionals are not
    sufficiently trained to diagnose or treat the disease of
    addiction, and most providing addiction care are not medical
    professionals and are not equipped to provide the full range of
    effective treatments.
        I believe in recovery. I believe in lives being restored
    and every individual living up to their full God-given
    potential and doing so drug free. I desperately want our
    federal efforts to work in every community and for every family
    that seeks care for addiction disorders. And I know working
    that together, at the federal, state and local level, we will
    achieve success. But we have to set our eyes on the goal of
    full recovery, not just addiction maintenance. We can do this,
    I have no doubt.
        We continue our oversight series today by listening to law
    enforcement and public health officials who are working at the
    on the front lines to protect our communities and our families
    in this national epidemic. We are grateful for your service and
    for taking the time to be with us today.

        Mr. Murphy. And with that, I now recognize Ms. DeGette of
    Colorado.

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

        Ms. DeGette. Thank you very much, Mr. Chairman, for
    convening this hearing today.
        As you noted, the opioid epidemic is nothing short of a
    public health crisis. In 2013, prescription painkillers were
    involved in over 16,000 overdose deaths, and heroin was
    involved in an additional 8,257 deaths. Over 2.1 million
    Americans live with a prescription opioid addiction while
    467,000 Americans are addicted to heroin. These are devastating
    numbers, and they have been trending upwards for far too long.
        These numbers only paint a partial picture of the heavy
    toll of the epidemic in our society. Throughout this country,
    countless families and communities have been shattered by
    opioid abuse, misuse and addiction. It is time that we really
    truly pursue best practices supported by scientific research
    that will reverse this problem.
        Recent advances in science have shown us that addiction is
    a disease of the brain. This demands that we approach the
    problem not only as a public safety issue but also as a public
    health issue. Yes, we must stop drug smugglers and crack down
    on pill mills, but we also must work with prescribers to
    educate them and prevent the over-prescription of opioids for
    pain management. And most importantly, we must improve our
    ability to identify and treat people with substance abuse
    disorders.
        In 2013, for example, only 1 in 10 Americans with a
    substance abuse disorder received any form of treatment. That
    is just unacceptable, and we should be asking why so few
    Americans are accessing the treatment they need.
        Research indicates that medication-assisted treatment, or
    MAT, combined with counseling is the most effective way to
    treat opioid addiction. Studies further demonstrate that MAT
    reduces the risk of drug overdoses, infectious disease
    transmission, and engagement in criminal activities.
        Despite this track record, in 2013, MATs were available in
    only 9 percent of substance abuse treatment facilities
    nationwide. Even more troubling are reports that some treatment
    facilities that adopt an abstinence-based approach to drug
    treatment do not allow patients to take MATs while enrolled in
    their programs. According to experts, a high percentage of
    opioid addicts in abstinence-based treatment return to opioid
    abuse within 1 year, and as you said, Mr. Chairman, even within
    a few weeks. Given the limited success of these programs in
    promoting long-term recovery in opioid addicts, we must ask
    some hard questions regarding how we should be spending our
    limited resources for treatment.
        Finally, we know that patients with substance abuse
    disorders continue to face significant barriers to treatment.
    For example, right now there is a nationwide shortage of
    qualified substance abuse providers, particularly people who
    can prescribe MATs. Recent press reports also suggest that
    patients face long waiting lists for admission into treatment
    facilities, and according to the American Society of Addiction
    Medicine, both State Medicaid programs and private insurers
    have policies in place that are limiting patients' access to
    MATs. We need to better understand these barriers and what we
    can do at the federal level to address them.
        There are some reasons for optimism, however. First, the
    Affordable Care Act has expanded access to substance abuse
    treatment for millions of Americans. Insurance companies are
    now required to provide coverage of treatment for substance
    abuse disorders just as they would for any chronic disease.
    These policies represent the largest extension of treatment
    access in a generation, and hopefully they will guide millions
    into successful recovery.
        Second, we do have some sense of what works. Some of our
    witnesses today who have firsthand knowledge on what strategies
    are effective to treat and prevent substance abuse will talk
    about that. They know what has worked in their communities, and
    we need to have them help us inform the national discussion.
        I do want to thank our witnesses today, Mr. Chairman. We
    have asked all of you to attend this hearing because of the
    important work that you are doing to raise drug awareness,
    break down the stigmas long associated with substance abuse
    disorders, and put people on the path to recovery.
        Finally, Mr. Chairman, your continued oversight on this
    issue gives me reason to be optimistic that this committee can
    play a role in turning the tide. You have indicated your
    intention to conduct a series of hearings on this topic, and I
    am certainly glad to be your partner in this inquiry.
        To that end, I suggest that our next hearing focus on state
    responses to the epidemic. There is significant variation from
    state to state on treatment quality, access and coverage. Some
    states are making progress but some are not, and we should hear
    the best practices. We also need to hear from federal agencies
    on these same topics.
        This committee has an opportunity to make a meaningful
    difference in addressing the problem, and I am welcoming all of
    our joint efforts.
        And with that, Mr. Chairman, I just want to let the
    witnesses know, this committee has a bill on the floor right
    now, so I have to run down and make a statement on the floor. I
    am leaving us in the capable hands of Mr. Kennedy, and I will
    be back after my statement. Thank you.
        Mr. Murphy. I thank the gentlelady, and thank you for your
    comments--very pointed.
        I now recognize the chairman of the full committee, Mr.
    Upton, for 5 minutes.

       OPENING STATEMENT OF HON. FRED UPTON, A REPRESENTATIVE IN
                  CONGRESS FROM THE STATE OF MICHIGAN

        Mr. Upton. Well, thank you, Mr. Chairman.
        Today we continue our important review of the growing
    epidemic of prescription drug and heroin abuse. The state and
    local perspective of this growing threat is essential as we
    evaluate what steps we can take at the federal level to help
    address the crisis.
        Sadly, communities all across the country have been
    affected by prescription drug and heroin abuse, including my
    district in southwest Michigan. Devastatingly, heroin overdoses
    sadly are on the rise due to a combination of high demand and
    purity that can make the drug even more lethal. There were 13
    suspected overdoses in Kalamazoo in the first quarter of 2013,
    compared to nine in the quarter before that in the earlier
    year. This unwelcome trend is unfortunately all too familiar as
    opiate-related overdoses have recently become the number one
    cause of death in Michigan and nationwide, surpassing motor
    vehicle crashes, suicide, firearms, and homicide.
        I know personally a number of families that have been
    shattered by that overdose. The reality of heroin overdoses has
    hit hard in Kalamazoo County the last few years. In 2008, we
    lost a beautiful little girl named Amy Bousfield, 18 years old.
    In 2012, Marissa King died at 21. She began using heroin in
    2009, despite having lost two friends to the drug. Marissa had
    an underlying mental illness. She was diagnosed with bipolar
    disorder, had struggled with depression, and had abused
    prescription drugs before turning to heroin after graduating
    from a local high school. These are just a few of the
    heartbreaking stories that we see all across the country. We
    are losing about 20,000 people a year from abuse of
    prescription pain killers or heroin.
        As we continue to mourn the loss of all these lives,
    testimony from you all today will provide us an effective
    approach making a real difference in fighting this awful abuse.
    This is a great opportunity for this committee, on a bipartisan
    basis, to help improve the federal government's response to
    this epidemic. I am especially pleased to welcome one of
    today's witnesses, my good friend Vic Fitz, the Cass County
    Prosecutor and the President of the Prosecuting Attorneys
    Association of Michigan. He has 31 years of experience in
    prosecuting drug cases, and will certainly share his insights
    today as he has done with me over the past number of years and
    with other fellow prosecutors in Michigan on this issue. I
    would note that the heroin dealer who sold the heroin that
    killed Amy Bousfield was caught, convicted, and sentenced to 10
    \1/2\ to 40 years in prison. We appreciate the work of Vic and
    his fellow prosecutors who have held dealers accountable to the
    law, and helped addicts straighten out their lives. I thank him
    and all of you for your service, and for participating at
    today's hearing, and I yield the balance of my time to Mr.
    McKinley.
        [The prepared statement of Mr. Upton follows:]

                     Prepared statement of Hon. Fred Upton

        Today we continue our important review of the growing
    epidemic of prescription drug and heroin abuse. The state and
    local perspective of this growing threat is essential as we
    evaluate what steps we can take at the federal level to help
    address this crisis.
        Sadly, communities all across the country have been
    affected by prescription drug and heroin abuse, including
    southwestern Michigan. Devastatingly, heroin overdoses are on
    the rise due to a combination of high demand and purity that
    can make this drug more lethal. There were 13 suspected
    overdoses in Kalamazoo in the first quarter of 2013, compared
    to 9 in the first quarter of 2012.
        This unwelcome trend is unfortunately all too familiar as
    opiate-related overdoses have recently become the No.1 cause of
    death in Michigan and nationwide, surpassing motor vehicle
    crashes, suicide, firearms, and homicide.
        The reality of heroin overdoses has hit hard in Kalamazoo
    County the last few years. In 2008, we lost Amy Bousfield, 18
    years old and a graduate of Portage Central High School. In
    2012, Marissa King died at 21 years old. She began using heroin
    in 2009, despite having lost two friends to the drug, including
    Amy Bousfield. Like 40 percent of those who abuse drugs,
    Marissa had an underlying mental illness. She was diagnosed
    with bipolar disorder, had struggled with depression, and had
    abused prescription drugs before turning to heroin after
    graduating from Comstock High School.
        There are many heart-breaking stories like this across the
    country. We are losing about 20,000 people a year from abuse of
    prescription pain killers or heroin. As we continue to mourn
    the loss of all these lives, testimony from today's witnesses
    provides us hope that there are effective approaches making a
    real difference in fighting opioid abuse. This is a great
    opportunity for this committee, working on a bipartisan basis,
    to help improve the federal government's response to this
    epidemic.
        I am especially pleased to welcome one of today's
    witnesses, my friend Vic Fitz, the Cass County Prosecutor and
    the President of the Prosecuting Attorneys Association of
    Michigan. Vic has 31 years of experience in prosecuting drug
    cases, and will share his insights as well as those of his
    fellow prosecutors in Michigan on this issue. I would note that
    the heroin dealer who sold the heroin that killed Amy Bousfield
    was caught, convicted, and sentenced to 10 and a half to 40
    years in prison. We appreciate the work of Vic and his fellow
    prosecutors who have held dealers accountable to the law, and
    helped addicts straighten out their lives. I thank him for his
    service, and for participating at today's hearing.

        Mr. McKinley. Thank you, Mr. Chairman, and thank you, Mr.
    Murphy, for holding this hearing today focusing on this growing
    epidemic. Thank you to the witnesses for coming here to
    testify.
        Prescription drug and heroin abuse has steadily increased.
    You have heard it throughout the comments that have been made
    here and throughout our country, and I have seen it firsthand
    in my home State of West Virginia. Currently, West Virginia is
    suffering from the highest rate of drug overdose mortality
    rates in the entire country.
        Since coming to Congress in 2010, our office has been
    working on solutions. We have had roundtable meetings
    throughout the district with law enforcement, healthcare
    professionals, educators, and community leaders about how to
    address this problem. What we have heard is at least three
    solutions. One is, we need to be focused better on education;
    secondly, on proactive prevention; and thirdly, resources for
    our law enforcement to take these drug traffickers off our
    streets. Therefore, by expanding the High Incident Drug Traffic
    Area--HIDTA--in West Virginia, it has provided an incredibly
    effective tool for catching drug offenders and taking them off
    the streets. This is just one option. I hope to learn more from
    the rest of this panel today.
        Thank you, and I yield back my time.
        Mr. Murphy. Thank you. The gentleman yield back. I now
    recognize Mr. Kennedy of Massachusetts for 5 minutes.

          OPENING STATEMENT OF HON. JOSEPH P. KENNEDY, III, A
          REPRESENTATIVE IN CONGRESS FROM THE COMMONWEALTH OF
                             MASSACHUSETTS

        Mr. Kennedy. Thank you, Mr. Chairman. Thank you very much
    to all the witnesses that are here today who have dedicated so
    much of their time, efforts, energy, and lives to confronting
    this crisis, either through treatment, community health or
    through law enforcement. We are grateful for your commitment
    and all you do to try to address this problem head-on, and I
    want to thank the chairman of the committee and of the
    subcommittee as well for calling an important hearing.
        There are few people in this country that have been spared
    the heartbreaking impact of watching a loved one, a neighbor, a
    friend, a colleague fall victim to opiate addiction. It is an
    epidemic striking red states and blue states, small towns and
    big cities, neighborhoods rich and poor. The breadth and depth
    of this epidemic is truly staggering, and there is no silver
    bullet. But perhaps there is a silver lining, which you have
    heard already this morning. It translates into strong
    bipartisan consensus here in Washington that we have to do
    something about it.
        Back home in the 4th District of Massachusetts, there is
    not an event that I go to where this topic does not come up.
    Communities like Fall River in Taunton have been particularly
    hard-hit. Local leaders are working tirelessly to respond.
        Across the Commonwealth, we confront a growing epidemic. In
    2013, there were 978 opioid-related deaths in Massachusetts,
    according to the Department of Public Health, which has yet to
    release 2014 figures. In fiscal year 2014, there were more than
    104,000 admissions to State-contracted substance abuse
    treatment programs in Massachusetts, more than 53 percent of
    which were for heroin addiction.
        Despite these numbers, I repeatedly hear from providers in
    my district that there is a profound lack of resources for the
    prevention and treatment of substance abuse, especially when it
    comes to opioid addiction. Insufficient wraparound services,
    low reimbursement rates, and bureaucratic barriers to treatment
    harm patients and undermine our efforts to reverse addiction
    trends.
        According to CPAC, the New England Comparative
    Effectiveness Public Advisory Council, 133,000 people in New
    England abuse or are addicted to opiates. Of those, 70 percent
    meet the criteria for treatment but cannot access it. We know
    that this is a problem with no silver bullet solution. We are
    working to chip away at it, and I am proud to have joined
    Representative Whitfield this morning in reintroducing
    legislation to reauthorize the NASPER program, the National All
    Schedules Prescription Electronic Reporting program. The
    program is designed to provide grants to states for the
    establishment, implementation, and improvement of prescription
    drug monitoring programs. We know that timely access to patient
    records and high standards of interoperability are successful
    with PDMPs, and this legislation will give providers the tools
    that they need to identify and treat at-risk behavior.
        To those of you who are here today to testify, you are on
    the frontlines of this epidemic. You are fighting every single
    day for our communities, our neighborhoods and our backyards.
    This gives you unparalleled insight into what works and to what
    doesn't. We are here today to learn from you, to take the
    lessons that you have learned from your cities and towns, and
    try to transport them across the entire country.
        Let me just say I first became aware of the scope of this
    addiction and the scope of this problem as a prosecutor in
    local communities in Massachusetts, finding young men and women
    that were breaking into 15 cars in a night, five, six homes
    over the course of the weekend, undercover agents that were
    putting themselves at great risk to try to keep our communities
    safe. So for those of you in law enforcement that are here, I
    look forward to hearing your ideas. From those folks back home
    that I have talked to, they have profound recognition that we
    will not arrest our way out of this problem, but very much look
    forward to hearing your solutions as to what we can do going
    forward, and I yield back my time.
        Mr. Murphy. I thank the gentleman for yielding your time.
    You are all done on your side? All right. Thank you.
        What we are going to do is, I am going to swear in the
    witnesses and then I am going to ask members who invited
    witnesses to introduce each one of you briefly, and hopefully
    we will get your testimony done before votes because we do want
    to hear from you and ask questions.
        So you are all aware that the committee is holding an
    investigative hearing, and when doing so has the practice of
    taking testimony under oath. Do any of you have any objections
    to giving testimony under oath? Seeing no objections, the chair
    then advises you that under the rules of the House and the
    rules of the committee, you are entitled to be advised by
    counsel. Do any of you desire to be advised by counsel during
    your testimony today? No one indicates they want counsel, so in
    that case, if you would all please rise and raise your right
    hand, I will swear you in.
        [Witnesses sworn.]
        Mr. Murphy. You may sit down. All the witnesses have
    indicated in the affirmative. You are under oath and subject to
    the penalties set forth in Title XVIII, Section 1001 of the
    United States Code.
        We will call upon you each to give a 5-minute summary of
    your written testimony. We will start off with Mr. Fred Wells
    Brason, and Mr. Hudson of North Carolina will introduce the
    witness.
        Mr. Hudson. Thank you, Mr. Chairman.
        I am pleased today to introduce Fred Wells Brason, a former
    hospice chaplain, now President and CEO of Project Lazarus from
    my home State of North Carolina. Mr. Brason has had tremendous
    success in saving lives from opioid overdoses, and I look
    forward to hearing his testimony and learning from his great
    work.
        Mr. Murphy. Mr. Brason, you are recognized--is it Brason or
    Branson?
        Mr. Brason. Brason.
        Mr. Murphy. Mr. Brason, you are recognized for 5 minutes.
    Turn the mike on, pull it close to you, watch the red light.
    That will tell you when you are done. Thank you.

    STATEMENT OF FRED WELLS BRASON, II, EXECUTIVE DIRECTOR, PROJECT
     LAZARUS, MORAVIAN FALLS, NORTH CAROLINA; DR. SARAH T. MELTON,
    PHARMD, BCPP, BCACP, CGP, FASCP, ASSOCIATE DIRECTOR OF PHARMACY
     PRACTICE, GATTON COLLEGE OF PHARMACY AT EAST TENNESSEE STATE
    UNIVERSITY, JOHNSON CITY, TENNESSEE, AND CHAIR OF THE BOARD OF
    DIRECTORS OF ONECARE OF SOUTHWEST VIRGINIA, BRISTOL, VIRGINIA;
     STEFAN R. MAXWELL, M.D., ASSOCIATE PROFESSOR, PEDIATRICS, WVU
      SCHOOL OF MEDICINE, MEDNAX MEDICAL GROUP, MEDICAL DIRECTOR,
    NICU, WOMEN AND CHILDREN'S HOSPITAL, CHARLESTON, WEST VIRGINIA;
       RACHELLE GARDNER, CHIEF OPERATING OFFICER, HOPE ACADEMY,
      INDIANAPOLIS, INDIANA; VICTOR FITZ, CASS COUNTY, MICHIGAN,
        PROSECUTOR, AND PRESIDENT OF THE PROSECUTING ATTORNEYS
    ASSOCIATION OF MICHIGAN (PAAM), CASSOPOLIS, MICHIGAN; CORPORAL
    MICHAEL GRIFFIN, NARCOTICS UNIT SUPERVISOR--K9 HANDLER, SPECIAL
       INVESTIGATIONS DIVISION, TULSA POLICE DEPARTMENT, TULSA,
    OKLAHOMA; AND DR. CALEB BANTA-GREEN, SENIOR RESEARCH SCIENTIST,
      ALCOHOL AND DRUG ABUSE INSTITUTE, UNIVERSITY OF WASHINGTON,
                          SEATTLE, WASHINGTON

                   STATEMENT OF FRED WELLS BRASON, II

        Mr. Brason. Thank you very much. Chairman Murphy, thank you
    for convening this and giving us the opportunity to share what
    is happening on the streets of our communities and our response
    to the issues that we encounter, and I am talking back to 2004
    as a hospice chaplain realizing the medication issues that were
    happening in our community homes where families were stealing,
    sharing, and selling the medication of and with the patients.
        Having addressed it that way and not having any solutions,
    we in Wilkes County, North Carolina addressed it from a public
    health perspective: this is our house, our community, and we
    need to fix it. And by doing that, we convened all the
    community sectors that we could, and working with each single
    one to derive a solution-based process from our schools to our
    law enforcement to our medical community to our prescribers,
    and in doing that, we created a public health model to sort of
    bring awareness to the issue but then also making sure that
    there is a balanced approached so that we are talking about
    prevention, intervention, and treatment across the spectrum. We
    do want to prevent the overdoses from occurring but we also
    want to ensure that patients can have access to care, receive
    the medication and the treatment that they are entitled to but
    receive it safely and appropriately, but then those individuals
    who do have and have developed a substance use disorder,
    disease of addiction and so forth, that they have a safety net
    so that they are not just pushed into the heroin or they are
    not pushed someplace else.
        A community has to address all of those facets, and we
    began by addressing first community awareness and community
    education so that individuals receiving a prescription can take
    it correctly, store it securely, dispose of it properly, and
    never share. Unfortunately, those are common practices that go
    on in our community with the right prescription for the right
    person but when it is in the home, the family is feeling like,
    well, it is OK because the doctor wrote it. Those are some of
    the public health reversals that we need to do. Then we work
    with our prescribing community to, you know, look at how to
    best manage chronic pain, how to manage acute pain, how to
    appropriately prescribe but then also how to assess patients,
    how to determine they are at risk, you know, possibilities, but
    then also looking within the community, and if there is a risk
    of something already has developed, who can I have the warm
    handoff to for the treatment that is necessary to them, whether
    it is an abstinence program, whether it is a medication-
    assisted treatment, whether it is a methadone or a
    buprenorphine or naltrexone. There isn't one treatment that
    works for everybody but there is treatment that works for
    everybody, so we have to make sure our communities have
    accessibility for all of that, and that is what we look for in
    our community and we are able to do that by education.
        When I first mentioned methadone, I thought I was leaving
    North Carolina permanently. It was not a pleasant time. But
    after education and understanding of what treatment is and how
    the brain is affected when somebody has been using for a while,
    there has to be a stabilization. There has to be a bridge, and
    we have to be able to provide that to those who are in trouble.
        But then as we address the prescribing community, then we
    also had to talk to our law enforcement, work with them on
    diversion techniques, the take-back programs, the permanent
    drop-offs for old meds in the home because in 2012, we did
    dispense 259 million prescriptions, which means we have
    accidental ingestion going on, especially among toddlers. So we
    have patients misusing, unfortunately overdosing. We have
    toddlers' accidental ingestion, unfortunately overdosing. We
    have families and friends sharing with unfortunate overdosing.
    We have recreational users going out for a good time and
    somebody having a pill for them dying from an overdose, and
    then we have those with substance use disorder dying from an
    overdose. Looking at all of those categories within our
    population groups, we have to address all population groups,
    all ages from a public health perspective to reverse the
    behaviors, the misconceptions, and the problems that arise from
    that but ensuring that those that need it can receive it, those
    that need treatment can receive it and have it.
        So as we did that, then we looked at, you know, what
    treatments could we bring into the community, and then we
    introduced naloxone. The North Carolina Medical Board was the
    first medical board in the country to come forth with a
    position statement that best practice is supporting and having
    an available naloxone, especially co-prescribing that with a
    medication to those individuals who are at risk. A person at
    risk could just be released from jail or person. A person at
    risk could be receiving methadone for treatment or for pain. A
    person at risk could be receiving opioid medication for their
    pain or they have a previous history for substance use. So,
    there is a broad base for the naloxone. It just needs to be
    made available, and thankfully, out of the State of Virginia,
    they are putting forth a law that sort of mandates co-
    prescribing of naloxone to a person receiving extended release
    or long-acting opioid medication. It is a safety factor. It is
    not a treatment but it is a rescue medication, and many of our
    communities now, especially Massachusetts, North Carolina and
    others, law enforcement are saving lives, and that is what is
    important to them. So it is a safety factor to do that.
        But without a comprehensive approach, there is not any one
    single bullet, there is not any one single thing. It has to be
    everything and it has to be all of us in order to drive the
    change from a public health perspective and have best practice
    from the individual to the prescribers, to the emergency
    departments, and everybody in between to accomplish that.
        Thank you for your time.
        [The prepared statement of Mr. Brason follows:]

      [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Mr. Murphy. Thank you very much.
        Now we are going to recognize Dr. Sarah Melton, and Mr.
    Griffith of Virginia is going to introduce you.
        Mr. Griffith. Thank you very much, Mr. Chairman.
        I am glad to introduce Dr. Sarah Melton. Dr. Melton chairs
    OneCare of Southwest Virginia, a consortium of substance abuse
    coalitions attempting to turn the tide against substance abuse.
    She is an Associate Professor of Pharmacy at ETSU and most
    recently was appointed by Governor Terry McAuliffe to the
    Virginia Task Force on Prescription Drug and Heroin Abuse, an
    idea first proposed to the Governor by myself and others in the
    Virginia Congressional Delegation.
        Dr. Melton has a long history of working to address the
    substance abuse problems in southwest Virginia. She was
    instrumental in bringing Project Lazarus to Virginia, and she
    is also working on the naloxone issues in southwest Virginia
    and in Virginia. I want to thank you, Dr. Melton, for being
    here today and sharing your experience with our committee.
        Mr. Murphy. Dr. Melton, you are recognized for 5 minutes.

                      STATEMENT OF SARAH T. MELTON

        Ms. Melton. Thank you, Mr. Chairman, and thank you,
    Congressman Griffith and the other members of the subcommittee.
        During my testimony, I am going to address key areas
    related to state and local initiatives that are making an
    impact, and I will also address key areas where I feel the
    federal government can assist in these areas.
        The first key area I will address is education of
    prescribers. As you are all aware, students and residents in
    healthcare professions have limited exposure to curricula in
    identifying and treating substance use disorders and
    appropriate prescribing and dispensing of controlled substances
    for chronic pain, but in Virginia, we are working together to
    bring leaders from all healthcare schools together to assure
    that our prescribers and dispensers of controlled substances
    have received an adequate education on addiction and the
    treatment of chronic pain.
        Overall, more funding is needed form the federal level to
    provide expanded graduate medical education opportunities for
    training in the identification, referral, and treatment of
    substance use disorders. As changes in federal funding
    allocated for graduate medical education are currently being
    discussed, it is an opportune time to assess how funding can
    best address training in addiction medicine.
        Tennessee has a mandated annual continuing education
    requirement for prescribers. Virginia, however, does not have
    that. OneCare of Southwest Virginia has joined with the Medical
    Society of Virginia and the Virginia Department of Health to
    provide no-cost continuing medical education to all healthcare
    prescribers as well as dispensers. We have been able to educate
    over 2,000 prescribers and dispensers in the past 3 years. We
    are currently evaluating how that continuing education has
    changed prescribing habits, attitudes, and registration to the
    prescription drug monitoring program as well as other outcomes.
        I wanted you to know that in January, a letter was sent
    directly from Secretary of Health and Human Services, Dr. Bill
    Hazel, to all prescribers in Virginia. The letter specifically
    addressed new legislation that requires prescribers to be
    monitored, to be registered in the prescription drug monitoring
    program, but it also talked about how to use the PMP programs
    in clinical practice. I am happy to report as a result of that
    letter, the prescription drug monitoring program registrations
    dramatically increased, and we are seeing a steady increase in
    inquiries to the PMP in the clinical setting. We are going to
    be sending a letter to all pharmacists in the Commonwealth in
    the next month.
        With regard to access to naloxone, both Virginia and
    Tennessee have recently passed legislation that will provide
    wide access to this lifesaving medication, and OneCare has
    worked extensively with the Virginia Department of Behavioral
    Health and Developmental Services to train people across the
    Commonwealth through Project Revive. Last summer, Senator Tim
    Kaine attended one of those trainings in Lebanon, Virginia, and
    as a result of his training, he has introduced legislation
    through the Opioid Overdose Reduction Act to offer Good
    Samaritan protection for first responders. It is my hope that
    Congress will pass this legislation so that we have a
    consistent Good Samaritan protection across the Nation.
        One barrier we are finding with naloxone, though, is the
    cost. It is not mandated by insurance companies to cover this
    medication, and it really should be.
        With regard to treatment, medication-assisted treatments
    with methadone, buprenorphine, and naltrexone have become an
    essential component of a comprehensive treatment plan for
    opioid use disorders. The issue that we have now is that we
    need a modernization of federal law to further expand access to
    these lifesaving medications but we need specific best practice
    requirements and recommendations for prescribers and insurers
    such as Medicaid and Medicare to make sure that certain
    patients are receiving comprehensive care by competently
    trained healthcare providers. Also critical is reimbursement
    for parts of these programs such as urine drug screens and the
    necessary psychotherapy that accompanies the medication
    treatment.
        With regard to monitoring with the prescription drug
    monitoring program, both Virginia and Tennessee are members of
    the National Association of Boards of Pharmacy Interconnect
    program, and I am very happy to find that the bill that will
    find NASPER is being proposed because the funding for that
    allocation will help all States be able to participate in a
    national prescription drug monitoring program. There is one
    concern I have, though. You may or may not know, a concern that
    we encounter daily in clinical practice is that methadone
    clinics are not required to report methadone dispensing to the
    prescription drug monitoring programs. This is a very serious
    situation because if these patients do not disclose this to
    their primary care providers and they don't know it when they
    access the prescription drug monitoring program, we often see
    other opioids being prescribed, benzodiazepines that can lead
    to death. So that is an issue of concern. And in contrast,
    buprenorphine, of course, is reported to the State prescription
    drug monitoring programs that allow us more monitoring for
    safety and appropriate use.
        Thank you for the opportunity to testify and for your
    ongoing commitment to this epidemic across the United States.
        [The prepared statement of Ms. Melton follows:]

     [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Mr. Murphy. Thank you.
        Now I am going to recognize the vice chair of the
    subcommittee, Mr. McKinley, to introduce Dr. Maxwell.
        Mr. McKinley. Thank you, Mr. Chairman.
        Dr. Stefan Maxwell is a neonatalist in Charleston, West
    Virginia, caring for the sickest of the newborns for the past
    30 years. He is Chairman of the West Virginia Perinatal
    Partnership, which focuses on reducing the number of babies
    born who are exposed to drugs. A study in this topic in 2009
    revealed that 20 percent, one in five, babies born in West
    Virginia were exposed to a substance during the pregnancy.
        Dr. Maxwell's work in the Perinatal Partnership in West
    Virginia has led to great strides in finding ways to identify
    women in need of drug treatment counseling and reduce the
    number of babies born exposed to drugs. His leadership as
    Chairman of the Perinatal Partnership and the Committee on
    Substance Abuse in Pregnancy, a member of the West Virginia
    Governor's Advisory Council on Substance Abuse, and caring for
    sick babies at Charleston Area Medical Center has made him a
    leading expert on this topic.
        Thank you, Dr. Maxwell, for attending here today and
    providing us your experiences.
        Mr. Murphy. Doctor, you are recognized for 5 minutes.

                     STATEMENT OF STEFAN R. MAXWELL

        Dr. Maxwell. Thank you Congressman McKinley and thank you,
    Mr. Chairman for the opportunity. It is pretty humbling to be
    asked to speak with such an august group, but hopefully this
    testimony will help us in your quest to quell this rising tide
    that is a scourge in our Nation.
        I have had the opportunity to take care of these babies
    that are suffering from neonatal abstinence syndrome, and so at
    the time back in 2006 when the West Virginia Perinatal
    Partnership was established, their mission was to look at areas
    that we could improve the health of mothers and babies in West
    Virginia, and at the time when all of the providers got
    together in a room, we decided that substance abuse in
    pregnancy or substance usage in pregnancy was an issue that we
    had to address, mainly because at the time, these babies that
    had neonatal abstinence syndrome were taking up most of the
    beds in the ICU, and level III institutions could not accept
    sick, small, premature babies from outlying institutions. Some
    of them had to be transported out of the State.
        So at the time, we really were not understanding the whole
    impact of what was happening in the State. So I missed a
    meeting and became chairman of the substance abuse committee, I
    have to say, and I was given that responsibility, and over the
    ensuing 3 years or so, we tried to figure out what was the
    prevalence of this problem in our State, and so we embarked
    upon the umbilical cord tissue study, which looked at eight
    hospitals through the State, scattered throughout the State. We
    collected as many umbilical cord tissue samples as we could as
    sort of a pilot over a month-long period. We ended up
    collecting almost 800 samples, and then we realized that one in
    five of those samples was positive for a substance, many of
    them being polydrug abusers, which included opiates, marijuana,
    and so forth.
        So this was obviously a daunting problem, and so at the
    Perinatal Partnership we decided to try to be proactive rather
    than reactive, and by that, I mean we wanted to see if we could
    reduce the numbers of babies with neonatal abstinence or at
    least reduce the severity of the neonatal abstinence syndrome
    at the end of the pregnancy. So we embarked upon a project that
    we called the Drug-Free Mothers and Babies Project whereby we
    sent out requests for proposals, got four or five in, and now
    have established four or five programs that are in the process.
    The aspects of this project are, one, we screen all women at
    the first antenatal visit, whether we do it using biological
    specimens like urine or we do it with screening tools such as
    what we call SBIRT screening, brief intervention, referral, and
    treatment. And then once we have identified a woman, a pregnant
    woman, who is using an opiate specifically, we then refer them
    to an addiction counselor and behavioral medicine, and try to
    follow them throughout that pregnancy with a goal to reducing
    or first of all converting the substance they are using to
    another drug that we can probably wean throughout the pregnancy
    with a goal to reducing the amount of drug that the baby is
    exposed to during the pregnancy and ultimately get them either
    off the drug or on a very small dose so that the severity of
    neonatal abstinence would be that much reduced.
        Well, one of those programs has been operating now for
    about 2 years, and we have had great success with one of those
    programs, reducing their incidence of 19 percent of positive
    umbilical cord tissue samples at birth to 8 percent, which
    means that the cost associated with neonatal abstinence has
    been significantly reduced. We have also been following these
    ladies who have been in the program for up to a year. We don't
    have 2 years' worth of follow-up yet, but the goal is to follow
    them at home for the first 2 years after delivery and reinforce
    that behavioral modification that went on throughout the
    pregnancy.
        The ultimate goal if this is a successful program is to
    develop what we call a pay-for-success program, whereby we can
    now try to save the government money in the long run by having
    an investor fund these programs, have an independent entity
    such as the Partnership administer the program with an
    independent audit, and at the end hopefully show that we have
    reduced the cost and ultimately improved the lives of these
    people that are ravaged by this terrible disease.
        Thank you for the opportunity, Mr. Chairman.
        [The prepared statement of Dr. Maxwell follows:]

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        Mr. Murphy. Thank you.
        Now we are going to go to Ms. Brooks to introduce her guest
    here today.
        Mrs. Brooks. Thank you, Mr. Chairman.
        Rachelle Gardner is here today representing the Hope
    Academy in Indianapolis, Indiana, in my district. Rachelle is
    the Chief Operating Officer and one of the founders of Hope
    Academy, a tuition-free Indiana public charter high school for
    students in recovery from drug and alcohol addiction.
        As 80 percent of students relapse from recovery upon
    returning to their own high school, Hope Academy is essential
    in combating the staggering statistic. Hope Academy is the only
    recovery high school in Indiana and one of only 35 within the
    United States. Rachelle also serves as the Director of
    Adolescent Services at Fairbanks Drug and Alcohol Treatment
    Center, and she is the Board Chair for the Association of
    Recovery Hospitals. And so I want to welcome Ms. Gardner and
    the other panelists today.
        Mr. Murphy. Thank you.
        You are recognized for 5 minutes. Thank you.

                     STATEMENT OF RACHELLE GARDNER

        Ms. Gardner. Thank you, Mr. Chairman and Congresswoman
    Brooks and members of the committee for allowing me to speak to
    you today. My name is Rachelle Gardner, and I have the
    privilege of serving as the Director of Adolescent Services for
    Fairbanks, an addiction treatment provider, and the Chief
    Operating Officer of Hope Academy, a recovery high school, both
    located in Indianapolis, Indiana.
        Hope Academy is the only recovery high school in Indiana
    and one of 35 recovery schools in the United States. For the
    last 4 years, I have served as the Chair of Board of Directors
    for the Association of Recovery Schools, also known as ARS, and
    the purpose of ARS is to support and inspire recovery schools
    around the country. My entire career has been dedicated to
    working with youth who are struggling with substance abuse.
        The abuse of opiates continues to rise in central Indiana.
    According to the Indiana University Center for Health Policy,
    the number of adolescents receiving treatment for opiate
    dependence has risen 9 percent over the last 5 years. One of
    the most staggering statistics is that since 1999, the number
    of opiate-related deaths has quadrupled in Indiana. Over the
    last 18 months, Fairbanks has admitted 360 young people ages 15
    to 23 who indicated opiates as their primary drug of choice.
        Heroin holds a firm grip on its victims and the withdrawal
    experience from this drug is extremely painful and challenging
    to overcome. Another danger of heroin is the significant
    potential for a fatal overdose. According to the Indiana State
    Department of Health, in 2011 there were 63 heroin-related
    deaths in Indiana and in 2013 that number increased to 152.
        All of the programs and services at Fairbanks for adults
    and adolescents are driven by our mission to focus on recovery.
    Recovery from alcohol and drug addiction is challenging for
    anyone, but especially for our young people who have yet to
    develop the coping skills necessary to work a successful
    recovery program.
        In the United States, 80 percent of students relapse from
    recovery upon returning to their high school following primary
    treatment for substance abuse. Fairbanks was seeing this same
    trend and in response, opened Hope Academy in 2006. Hope
    Academy is a public charter school sponsored by the Mayor of
    Indianapolis. We serve students in grades 9 through 12 who are
    seeking a safe, sober, and supportive environment. We are
    committed to small class sizes with highly qualified teachers
    who are well trained to educate and support students in
    recovery from drug and alcohol addiction. Most of our students
    struggle with co-occurring behavioral and mental health issues
    as well, yet because of the expertise of our staff, we are able
    to address these issues.
        The key to a successful recovery program is changing the
    people, places, and things in your life. Sending a child back
    to their former school puts them in the environment that may
    have led to their drug and alcohol use. Hope Academy provides
    these students with an environment that contributes to academic
    success, personal growth, and life-long recovery. Our students'
    success is measured in growth. We define growth in many ways:
    the number of days they remain abstinent from drugs and
    alcohol, their ability to obtain credits and graduate,
    repairing relationships with families and friends, and
    developing much-needed life skills.
        Over the last 9 years we have served more than 500 students
    at Hope Academy. Some of these students felt strong enough in
    their recovery to successfully transition back to their home
    schools and graduate. Yet over 100 students chose to stay and
    are now alumni of Hope Academy. Many have pursued postsecondary
    education or advanced vocational training with the goal of
    joining the workforce and contributing positively to their
    communities.
        Academic achievement and recovery success are our primary
    goals at Hope Academy. We have partnered with Indiana Wesleyan
    University's Addictions Counseling Program to produce a Web
    site for the purpose of sharing research outcomes with other
    recovery schools around the country. One recent study produced
    data that strongly suggests students attending Hope Academy
    were overall persistent in their education, which in turn
    reduced their behavioral and mental health issues while
    increasing the strength of their recoveries.
        Through my work with the Association of Recovery Schools, I
    have become quite familiar with the national advocacy efforts
    surrounding the Comprehensive Addiction and Recovery Act of
    2015, or CARA. Last year, Senator Whitehouse of Rhode Island
    and Senator Portman of Ohio submitted this critical piece of
    federal legislation. If passed, this would authorize increased
    funding for treatment, recovery, and criminal justice systems
    while aiming to reduce opioid misuse and overdose deaths. In
    section 303 of CARA, the National Youth Recovery Initiative is
    of special importance to the various organizations I represent
    because of the attention it pays to adolescent treatment and
    recovery resources. Each of you can help us get the resources
    needed to make a lasting impact on the opiate crisis at a
    national level by first empowering our local communities. This
    passage of legislation is critical to helping our youth, our
    families and our communities who are fighting this epidemic on
    a daily basis.
        The disease of addiction has permeated our society for
    hundreds of years. In my 25 years of experience, I have never,
    ever seen a class of drugs take hold of young people like I
    have with opiates. They are highly addictive and too often lead
    to premature death, which unfortunately I have seen way too
    many times. Opiates are claiming the lives of our country's
    future leaders.
        My hope in testifying today is that together we can not
    only provide young people the access to treatment and recovery
    supports they need but also to restore their hope for a
    positive future.
        Thank you for the opportunity to be here today and I look
    forward to answering any of your questions.
        [The prepared statement of Ms. Gardner follows:]

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        Mr. Murphy. Thank you, Ms. Gardner.
        Now, Mr. Fitz, I will recognize you. You are the prosecutor
    of Cass County, Michigan, also the President of the Prosecuting
    Attorneys Association of Michigan. Welcome here. You are
    recognized for 5 minutes.

                        STATEMENT OF VICTOR FITZ

        Mr. Fitz. Chairman Murphy and esteemed members of the
    Oversight and Investigations Subcommittee, as indicated, my
    name is Victor Fitz and I am the prosecutor in Cass County,
    Michigan. Cass County is a medium-sized county in lower
    Michigan abutting South Bend on the Indiana border. We are
    equidistant from Chicago and Detroit, 2 hours to the west of
    Chicago, 2 hours to the east is Detroit. I want to thank you
    for the opportunity to be here today both on behalf of the Cass
    County Prosecutor's Office as well as the Prosecuting Attorneys
    Association of Michigan, particularly to address this very
    serious and horrifying epidemic that we are facing in Michigan
    as well as the Nation as a whole.
        Michigan, like the rest of our States, is extremely diverse
    from county to county, but we are all similar in one way,
    Michigan from our Upper Peninsula to the shores of Lake
    Superior right down to our urban areas of Detroit, Saginaw,
    Muskegon, Flint and the like, and that is that we are dealing
    with the devastating problem of prescription drug abuse and
    heroin abuse. It is devastating all of our communities. It is
    not just an inner city problem. It is not just a rural problem.
    It is there and everywhere in between.
        All people are vulnerable to abusing these drugs because
    they are so very addictive. This abuse can start innocently,
    for instance, a teenager who becomes addicted to OxyContin
    after a serious athletic injury or someone perhaps
    recreationally who starts using less addictive drugs and
    graduates their drug use to heroin. It takes only one time to
    become addicted to heroin, and that one time is ruining
    futures, it is ruining families, and it is ruining lives.
        The opiates found in prescription pills are the addictive
    ingredient in heroin, and that is why users of prescription
    drugs eventually seem to turn to heroin. It is also simple
    economics. As we have found in Michigan as well as other parts
    of the Nation, it is actually cheaper to use heroin than
    prescription drugs on many occasions. We found in Michigan that
    heroin is actually cheaper in many areas than even marijuana.
    It can be smoked, it can be snorted, and it can be injected. It
    is quick and it is easy.
        Statistics in the State of Michigan indicate that in the
    year 2001, there were 271 heroin overdose deaths in our State--
    I am sorry. That would have been the year 2001 and 2002, a 2-
    year period. Fast-forward to 2011. That number quadrupled. For
    one year, the year 2011 had 728 heroin deaths.
        I know the congressional representative from Colorado spoke
    earlier about the 8,000 heroin deaths in the United States, and
    allow me just for a moment to personalize that from a
    prosecutor's perspective, from a law enforcement perspective.
    We had about 2 years ago in Cass County and Bering County in
    southwest Michigan, our two counties, we had a heroin death
    that occurred, or suspected heroin death. In Michigan we now
    have a law that indicates that if you deliver heroin or any
    drug and that causes the death of that person, it is the
    equivalent of a second-degree murder charge. Unfortunately,
    because of the newness of this statute, law enforcement not
    having protocols, did not seize upon the opportunity to
    investigate in that fashion initially. So as the investigation
    did take forward once my office became aware of it by the
    exhumation of the body, which I can tell you was something that
    was quite traumatic to the victims of the teen who had been
    killed from suspected drug activity. While that investigation
    was going on, in an effort to show that the death came from the
    use of heroin and other drugs that were supplied, this
    individual was still out on bond and he again delivered to
    another person, who also died from a heroin overdose. I can
    tell you that the pain and the agony is palpable for the
    victims and for those families.
        On Monday of this week, I was talking to another family of
    a homicide situation, didn't happen to be drugs, but I can tell
    you when it is a violent death, when it is a death from a drug
    overdose, the pain never leaves the family. Again, these are
    real. The number 8,000, as mentioned earlier, every one of
    those is a tragedy for the family and for the community and for
    the friends.
        We are also seeing pre-teenagers abusing prescription drugs
    and heroin. It is a terrifying tragedy. Anything that we can do
    to battle this epidemic needs to be done. The Michigan
    Department of Community Mental Health in my State has developed
    a work group to design a strategic plan to combat this type of
    drug abuse. The plan, which is in place through the year 2015
    through September 30, 2015, generally recommends the following:
    increasing multisystem collaboration across agencies,
    broadening statewide media messages, increasing training for
    physicians regarding drug abuse for education in schools, and
    increased access to databases regarding controlled substances
    for health professionals and law enforcement. In my written
    testimony, I provide some other potential options in that
    regard. Anything we can do to combine strategies and improve
    operations to get our citizens help and to put an end to what
    is deteriorating lives should be done.
        If I could have just one moment, I want to mention very
    briefly our prosecutor from Wayne County in the Detroit area.
    Kim Worthy asked me this morning to just pass on a couple
    things very quickly that again this is not just a rural issue,
    it is also an urban issue, and they have excessive pill mills,
    violent crime, robbing of pharmaceutical vehicles going through
    their neighborhoods, murders occurring from these situations,
    and she again emphasizes we need to attack it on both the
    supply and the demand end.
        Thank you very much.
        [The prepared statement of Mr. Fitz follows:]

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        Mr. Murphy. Thank you very much.
        Now Corporal Mike Griffin will be introduced by Mr. Mullin
    of Oklahoma.
        Mr. Mullin. Thank you, Mr. Chairman.
        It is a very great privilege I have to introduce not just
    Corporal Mike Griffin but a friend of mine. Mike and I used to
    meet just about every Friday morning to have breakfast, and in
    his words, he says just to help me stay grounded.
        Mike has worked with the Tulsa Police Department for 17
    years and spent 12 of those years in an undercover capacity
    conducting drug investigations. For the past 10 years, he's
    been a supervisor within the department's narcotics unit.
    Previously, Corporal Griffin was with a special agent with the
    Bureau of Alcohol, Tobacco, and Firearms. He has also served as
    a member of the Oklahoma Army National Guard. Mike, thank you
    for being here today.
        Mr. Murphy. You are recognized for 5 minutes.

                      STATEMENT OF MICHAEL GRIFFIN

        Mr. Griffin. Chairman Murphy, Ranking Member DeGette, and
    members of the committee, on behalf of Chief Chuck Jordan and
    the Tulsa Police Department, thank you for the opportunity to
    discuss prescription opioid abuse, heroin abuse, and heroin
    trafficking.
        Although heroin abuse and trafficking in Tulsa lags far
    behind the abuse and tracking of methamphetamine, heroin is
    trafficked into Tulsa in the same manner as methamphetamine and
    cocaine, and its abuse leads to similar related criminal
    activity ranging from petty larceny to armed robbery and even
    murder.
        Narcotics investigators within the Tulsa Police Department
    know that a large majority of individuals currently addicted to
    heroin began their drug abuse by abusing prescription drugs.
    The Tulsa Police Department currently has 751 sworn police
    officers. TPD believes the focus of drug investigations should
    be on those individuals who are responsible for trafficking
    drugs into and through our community rather than on those
    individuals who are merely addicted to drugs. This is because
    of our belief that resources are best utilized at the source of
    the problem rather than on the symptoms of a problem. With that
    goal in mind, of the 751 sworn officers working for TPD, one
    investigator is assigned to investigate prescription drug cases
    within the city. Our lone prescription drug investigator spent
    the last 20 years investigating prescription drug cases. He
    believes that Oklahoma has one of the best prescription
    monitoring programs in the United States. Oklahoma's PMP is
    real time and allows doctors and pharmacists to quickly access
    an individual's prescription drug history to evaluate if they
    are possibly doctor-shopping to gain access to prescription
    drugs.
        If a person gets addicted to opioids, it is not long before
    they realize that obtaining prescription drugs are harder to
    access due to Oklahoma's PMP and more expensive than heroin.
    Because these individuals already are addicted to opioids, the
    transition to heroin is easier and cheaper.
        Heroin trafficking in Tulsa is operated by Mexican drug
    trafficking organizations. Similar to other drug investigations
    conducted at the local or state level, the individuals most
    often arrested and prosecuted are the local dealers and
    operation leaders. However, the individual profiting most from
    the illegal distribution of heroin resides in Mexico and is
    usually beyond prosecution at the state level.
        Additionally, and still consistent with other drug
    investigations, when the individuals at the local or state
    level are arrested, Mexican DTO simply replaces those
    individuals with other low-level people within the
    organization. Therefore, the drug-trafficking organization is
    able to continue distributing drugs within a community almost
    uninterrupted.
        Data confirms that drug abuse not only provides a demand
    for drugs to be trafficked into and throughout the United
    States but also that drug abuse and distribution leads to other
    crimes occurring in a community. An approach targeting drug
    trafficking without taking into account a need to prevent drugs
    from even entering the United States is shortsighted. Prior
    efforts by law enforcement agencies and state legislators to
    prevent drug crimes and crimes that occur because of drug
    dependence and distribution have shown to be successful. For
    example, reducing the availability of pseudoephedrine has shown
    to reduce the number of meth labs operating in Oklahoma and
    other States with similar legislation. This legislation has not
    only reduced the number of meth labs operating within a state
    but is also shown to significantly lower associated criminal
    activity. According to the FBI, no other country in the world
    has a greater impact on the drug situation in the United States
    than does Mexico. The FBI states that each of the four major
    drugs of abuse are either produced in or transported through
    Mexico before reaching the United States.
        Mexican drug-trafficking organizations use numerous methods
    to smuggle drugs into our country to include aircraft, horses
    and mules, tunnels, vehicles, and even people walking across
    the border. Data provided by the DEA shows that the supply of
    heroin coming from Mexico has increased over the past 5 years
    and that part of the increase in heroin seizures may be due to
    the decrease in U.S. demand for Mexican marijuana, which has
    led Mexican drug farmers to increasingly plant opium poppies in
    lieu of marijuana.
        It is clear that prescription opioid abuse and the related
    heroin abuse are issues that affect communities across the
    United States. Without a comprehensive approach to these
    issues, many people across the county will continue to be
    affected by these drugs.
        The Tulsa Police Department recommends a continuation of
    the comprehensive approach to drug trafficking currently in
    place, which relies on coordination among law enforcement
    agencies, community-oriented policing, intelligence and
    information sharing, and improved technology. The Tulsa Police
    Department also encourages additional federal efforts be made
    to prevent drugs of all kinds from crossing our international
    borders and finding their way into communities across the
    United States.
        [The prepared statement of Mr. Griffin follows:]

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        Mr. Murphy. Thank you, Corporal. I appreciate your
    testimony.
        Last but not least is Dr. Banta-Green, Senior Research
    Scientist at the Alcohol and Drug Abuse Institute at the
    University of Washington in Seattle.
        Doctor, you may now give a 5-minute summary of your written
    statement.

                     STATEMENT OF CALEB BANTA-GREEN

        Mr. Banta-Green. Good morning, Chairman Murphy and members
    of the committee. I am honored to speak to you today about how
    we can improve the health of our communities as they struggle
    with how to manage stress, pain, and addiction in a society and
    a healthcare system that has historically valued and
    incentivized quick fixes over real health and wellness. We face
    big challenges but we do know what needs to be done.
        I am a Senior Research scientist at the Alcohol and Drug
    Abuse Institute at the University of Washington, where I am
    also Affiliate Faculty in the School of Public Health and the
    Harborview Injury Prevention and Research Center. My current
    work includes leading a study of an intervention to prevent
    opioid overdoses among heroin and pharmaceutical opioid users
    that is funded by the National Institutes of Health. I have a
    project analyzing prescription monitoring program data and
    developing interventions with those data to improve health for
    those taking controlled substances. This is funded by the
    Bureau of Justice Assistance with an award to our State
    Department of Health; and I am currently running the Center for
    Opioid Safety Education which supports communities across
    Washington State so that they can respond to the overwhelming
    impacts of opioid abuse and overdose in their communities. That
    funding is from the SAMHSA block grant to our state substance
    abuse agency.
        As a public health researcher, I think in terms of primary
    prevention--preventing a problem from starting; secondary
    prevention--intervening in a problem to prevent it from getting
    worse; and tertiary prevention--to prevent death and serious
    harm.
        Given that our communities are in crisis, let us start with
    preventing death and serious harm. Overdoses can be prevented
    and most can be reversed before they become fatal if people
    know how to recognize an overdose and how to respond. Overdoses
    are a crisis of breathing. 911 needs to be called. An antidote,
    naloxone, needs to be administered, rescue breathing needs to
    be initiated and the overdose victim needs to be monitored.
    Naloxone is a proven, safe medication yet far too few people
    who need it even know about it, can get it easily or can afford
    it. Overdose education on naloxone can be provided in a
    doctor's office, by a pharmacist, at jails or via community-
    based health education programs such as syringe exchanges.
    Those at highest risk for overdose are heroin users. Syringe
    exchanges have the staffing expertise and trusting
    relationships with our loved ones who use heroin that are
    necessary to provide lifesaving services.
        At the same time, far more people are using pharmaceutical
    opioids. About 3 percent of adults use opioids chronically for
    pain. They also need overdose education and take-home naloxone.
        Fatal overdose prevention is a necessary first step, but it
    is a short-term emergency response. Given that opioid addiction
    leads to changes in the brain and that addiction is a chronic
    and relapsing condition, it needs to be treated as a chronic
    medical condition. We are fortunate to have medications to
    support opioid addiction recovery. Methadone and buprenorphine
    have been consistently shown in research to save lives and be
    cost efficient. However, access is still limited by regulatory,
    geographic, and financial barriers.
        Switching to those using opioids for chronic pain,
    realistic expectations about pain relief need to be discussed,
    including the fact that long-term opioid use may not lead to
    good pain control and in fact may reduce functioning.
    Washington State has led the nation by implementing chronic
    pain management guidelines in 2007 which have subsequently been
    codified in State law. Key points of these guidelines include:
    a dosing threshold trigger for consultation with a pain
    specialist; patient evaluation elements; periodic review of a
    patient's course of treatment; encouraging prescriber education
    on the safe and effective uses of opioids; and the use of
    medication-assisted treatment if a person is not successfully
    tapered off of opioids and has an opioid use disorder.
        So, how do we prevent opioid addiction in the first place?
    Given that the majority of young adult heroin users now report
    they were first hooked on pharmaceutical opioids, it is clear
    that addressing inappropriate initiation is essential. The
    decision to begin prescribing opioids for minor injuries and
    pain needs to be carefully considered as does the total
    quantity dispensed if they are prescribed. Opioids in the home
    need to be carefully monitored and immediately disposed of when
    no longer needed. Parents need to know how to talk with their
    kids about medication safety as well as how to manage stress
    and pain without medications, drugs, or alcohol.
        To conclude, we can keep people alive, we can treat harms
    related to opioid use and we can prevent misuse, but, given the
    potential harms of improper care for those with opioid use
    problems, we need to take a strategic approach based upon the
    fact that pharmaceutical opioids can be used interchangeably
    with heroin and we need to work on prevention and intervention
    simultaneously.
        Thank you very much.
        [The prepared statement of Mr. Banta-Green follows:]

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        Mr. Murphy. I thank the entire panel. We will try and get
    through as many questions of members as possible, and we will
    have votes, but we will continue on because one vote will be
    brief.
        So Dr. Melton, let me start off with you. What is the goal
    of medication to deal with opioid addiction? Is it to keep the
    addict maintained for life or is the goal to have it part of a
    program of getting the person clean and sober from the drugs?
        Ms. Melton. That is a great question and a point of
    controversy in the clinical setting. Of course, to me the goal
    of medication-assisted treatment is to provide a treatment for
    the patient where they are able to do the hard work and become
    productive members of society. And so the way I think of it as
    a patient who has addiction has constant craving and constant
    thoughts of where am I going to get my next opioid. When they
    are prescribed methadone or buprenorphine, the craving is
    relieved and they are able to focus their efforts on doing the
    really hard work that is necessary, and that is the
    psychotherapy, group, 12-step programs, et cetera. So the
    overall goal is for the patients to receive the treatment for a
    limited period of time. We usually tend to think of it as 2
    years, 1 year for them to become stable and do the hard work
    and perhaps a year to taper off of it. However, there are some
    patients that are wanting to have this maintenance for life. We
    know we have seen that in some patients, but the goal is
    eventually for them to be productive members of society and not
    to be maintained long-term.
        Mr. Murphy. I am looking at a study here that was in the
    New England Journal of Medicine by Johnson, et al, and it
    reports that patients on buprenorphine used illicit opioids an
    average of four times per week. So I don't know how much that
    is working. Can you comment on that?
        Ms. Melton. Well, what I would say with that and I address
    in my testimony is that we are in dire need of more regulations
    and recommendations on evidence-based care of how these
    programs should be run. We know in Tennessee and southwest
    Virginia some buprenorphine programs have become pill mills
    where the physicians charge them high prices, they come in and
    get their medication, and they leave.
        Mr. Murphy. So there is an incentive, are there incentives
    because there are cash transactions in many cases and what you
    describe, they become pill mills? Is that what it has become?
        Ms. Melton. Yes. We are seeing that, and it is devastating
    in many circumstances. There is a dearth of access to good
    treatment, and by ``good treatment,'' I mean patients being
    seen frequently, getting urine drug screens at nearly every
    visit, if not every visit, requiring 12-step programs, group
    counseling, and not co-prescribing with other drugs of
    addiction such as benzodiazepines.
        Mr. Murphy. Because otherwise with the government funding
    these things, we are just in that great term that we use, the
    clinical terms, we are codependents, we are enablers if we
    create these incentives.
        I move on to another--Dr. Brason, your experience with
    Project Lazarus, what has been the most effective approaches in
    getting addicts completely off drugs?
        Mr. Brason. Getting patients off----
        Mr. Murphy. Yes, off drugs.
        Mr. Brason. A comprehensive approach and determining and
    assessing that individual of what the best treatment modality
    may be. Some can walk right into a 12-step abstinence program.
    Others who have been using for even longer then do need that
    maintenance therapy in order to give them that stability so
    that you can work on their entire life. Now, somebody who is
    getting the methadone or the buprenorphine can receive that,
    and that takes maybe--if they are getting daily dosed--an hour
    and a half a day. What happens to the other 22, 23 hours of
    that person's life when they had gone from 24/7 of looking to
    use, getting to use and figuring out where they are going to
    obtain that? It takes community support. You have got to have
    the life systems around that individual so that if they are
    getting the right maintenance therapy or the right 12 steps,
    they have got the counseling, they have all of those in place,
    but what happens when they go home? You talk about a rural
    community. They leave their house or they go to detox and they
    leave detox during the same home, same environment, same
    friends. If there is no other support around that to help them
    stay strong in that environment, then they fall back into the
    same situation.
        Mr. Murphy. So somewhere out there in America, we hope
    someone is watching this hearing that themselves is dealing
    with drug addiction. If you had a chance to look them in the
    eye and say something to that addict, what do you say?
        Mr. Brason. My word to them would be: We are here, I am
    here to help you, and let us walk through this together to see
    what best works for you so that we can then work on all the
    circumstances, situations, and issues that brought you to that
    place. We can talk about the drug problem, but what caused all
    of that?
        Mr. Murphy. And in simple words too, Ms. Gardner, is there
    hope? Can you give someone hope that they can get off drugs?
        Ms. Gardner. Well, we have talked a lot about the disease
    and the negative effects and the horrible things that happen
    with this disease, but there is hope. There are lots of people
    across this country staying clean and sober, have multiple
    years. I get the pleasure of working with young people,
    watching them graduate, watching them go on to postsecondary
    education, watching them become productive members of the
    communities.
        I work with lots of young people around the country who
    have gone through similar situations through high school and
    collegiate recovery that are doing great things. There is a lot
    of hope. I agree with the panelists. We are all saying the same
    thing. It is a comprehensive approach to this between
    medications, between law enforcement, between schools, between
    educating doctors. There is hope.
        Mr. Murphy. Thank you.
        Ms. Gardner. And we need to focus on the hope.
        Mr. Murphy. Thank you.
        I am out of time, and I will recognize Ms. DeGette for 5
    minutes.
        Ms. DeGette. Thank you very much, Mr. Chairman.
        Dr. Banta-Green, I was very interested in your testimony
    that when somebody becomes addicted to opiates, there are
    actually changes in their brain. Is that right? And I am
    assuming, Dr. Melton, you would agree with that as well from
    your testimony. You need to answer.
        Ms. Melton. I agree, yes.
        Ms. DeGette. Thank you. And so Dr. Banta-Green, I think
    this is why you are saying that somebody who is addicted to
    opiates, the best treatment is not just to have counseling or a
    12-step program for most patients; they also need to have
    something to sort of rejigger their brain. Is that right? That
    is not a scientific term, by the way.
        Mr. Banta-Green. Rejigger? I am not familiar with that one,
    but I know what you mean. So I think that is right. I think
    what we need, as Mr. Brason said, is we need a range of
    options.
        Ms. DeGette. Right.
        Mr. Banta-Green. We need a menu of things. Different things
    work for different people.
        Ms. DeGette. And would you agree with that, Dr. Melton?
        Ms. Melton. I also agree, yes.
        Ms. DeGette. And so what we have learned is, and we have
    been referring to this, there was a recent article that said
    that abstinence-based treatment only works in about 10 percent
    of opiate addicts. Would you agree with that, Dr. Banta-Green?
        Mr. Banta-Green. I am not sure it is exactly 10 percent.
    What I----
        Ms. DeGette. But it is a low percentage, right?
        Mr. Banta-Green. It is a minority. I think it is
    important--Dr. Roger Weiss at Harvard had a paper come out last
    month that followed up after 42 months people who had started
    on buprenorphine. Some did well at the front end. Some did not.
    After 42 months, only 8 percent were still addicted to opioids
    but about a third of those people had managed to not be on
    medication-assisted treatment but many had still been on
    medication-assisted treatment.
        Ms. DeGette. OK.
        Mr. Banta-Green. There are different paths for different
    people.
        Ms. DeGette. Yes, but the best protocol would be for these
    folks to have the option to have the medication-assisted
    treatment, the MAT, plus the counseling that Dr. Melton talked
    about?
        Mr. Banta-Green. Absolutely. There is no question about
    that.
        Ms. DeGette. And were you aware that the MAT treatment was
    only available in about 9 percent of all substance abuse
    treatment facilities nationwide?
        Mr. Banta-Green. I know that it is a very low proportion.
        Ms. DeGette. And Dr. Melton, were you aware of that too?
        Ms. Melton. Yes.
        Ms. DeGette. OK. And Mr. Brason?
        Mr. Brason. Yes.
        Ms. DeGette. Now, Dr. Melton, you probably see this in your
    practice. One of the biggest problems that we have with the
    lack of the MAT treatment is in rural areas. Is that true in
    the areas where you practice?
        Ms. Melton. That is correct.
        Ms. DeGette. And Mr. Brason, you are nodding your head. Are
    you seeing that too?
        Mr. Brason. That is correct also, yes.
        Ms. DeGette. Now, I am hearing from folks--and you know,
    for those of us who are concerned about over-prescription of
    opiates, who are concerned about young people getting addicted
    to heroin and other opiates, the idea of substituting one for
    another like with methadone or other drugs, that sort of goes
    against our instincts, but in fact, I guess I will ask this
    question: Is the use of those medications simply replacing one
    addiction with another, Dr. Banta-Green?
        Mr. Banta-Green. No. A person who is being managed on
    medication-assisted treatment, per the Diagnostic and
    Statistical Manual, the American Psychiatric Association, it is
    not addicted anymore. They are physiologically dependent on
    opioids. We need to separate out addiction from dependence.
    Addiction is what we see, all the social and psychological
    pieces plus the physical. You address the physical and then you
    can deal with the rest.
        Ms. DeGette. And Dr. Melton talked about how if you can get
    folks into adequate treatment with the MATs, then with the
    counseling, she said the goal would be sort of a 2-year
    process. One is to get them to be stabilized and thinking, and
    the other one is to get them off. Would you agree with that
    type of thought?
        Mr. Banta-Green. No.
        Ms. DeGette. OK.
        Mr. Banta-Green. I would say that the goal is for the
    person to do well, and for some of them, that is going to be to
    go off the medications immediately. They are not going to do
    well on those medications. For other people, they are going to
    have a short period. For people who have been involved in
    addiction and a lot of their life has been wrapped around it
    for 10, 15, 20 years, that is going to take a long time to work
    through and it is going to take a longtime for them to recreate
    that life. So some people may need to be on them long term,
    some not at all, some short term.
        Ms. DeGette. So Dr. Melton, what would you say about my
    question about is the use of these medications simply replacing
    one addiction for another?
        Ms. Melton. Absolutely not. I agree with him. It is not
    addiction. We are getting them into a state of where those
    behaviors that meet the criteria for addiction are gone. They
    are now in a state of physiologic dependence on the opioid, but
    because of that dependence, they are able to do the hard work
    that we have discussed, and I totally agree when I said the 2-
    year, when you look at insurance companies, they limit
    buprenorphine a lot of times to 2 years.
        Ms. DeGette. OK.
        Ms. Melton. But for some people, it will be a lifetime, as
    I said.
        Ms. DeGette. And for some people, they don't even need the
    MATs, right?
        Ms. Melton. Some people are able to do abstinence.
        Ms. DeGette. And you agree with that too, Mr. Brason?
        Mr. Brason. Yes, I do.
        Ms. DeGette. Thank you very much, Mr. Chairman.
        Mr. Murphy. Thank you, Ms. DeGette. I now recognize Mr.
    McKinley for 5 minutes.
        Mr. McKinley. Thank you again, Mr. Chairman.
        Two things, and if I could direct those to Dr. Maxwell. You
    said something that I found very intriguing in your remarks and
    also in your testimony, and that was about pay for success, and
    I spent a little time, I was looking--I did a little research,
    the beauty of Google, to be able to read that, and I understand
    that program may be working across the country. Can you give us
    a little bit more information about, one, the program of pay
    for success, and two, this proactive role that you talked about
    for drug-free moms and babies? I am curious about it because
    what I am hearing from you is that you have actually got
    programs to solve this, and so I am curious to see, or at least
    address it. Could you answer both of those two questions?
        Dr. Maxwell. I will try, sir. The pay-for-success model I
    was introduced to last year when I attended as one of the
    representatives for our State at Readynation.org meeting in
    Charlotte, which was their first meeting, and they have brought
    this pay for success or social impact bond concept to the
    United States based on Great Britain's experience a few years
    ago looking at recidivism rates for juveniles going back into
    jail, and they had some success in Great Britain. The program
    was brought here by Robert Dugger and some other members of the
    ReadyNation organization, and I can't tell you exactly how many
    States but Virginia, North and South Carolina, I think New
    Jersey have implemented some of these programs. Some are
    actually social impact programs, some are pay-for-success
    programs looking at early childhood education and so forth.
        I was intrigued when I heard of the model, and the model, I
    will have to read it for you because it makes a little bit more
    sense if I read it. Under this model, an investor finances the
    implementation of a proven or evidence-based social
    intervention program that is expected to improve social welfare
    and save government money in excess of the program
    implementation cost. So the government at the end repays the
    investment only after the program can measurably reduce state
    expenditures as a result of its successful implementation. So I
    thought that looking at our drug-free moms and babies model,
    that if it in fact is successful, that we could have this end
    up in a pay-for-success program because you identify women
    early in pregnancy using a screening tool, and as I said, urine
    is not a very good screening tool because if the woman has not
    done a substance in 2 or 3 days, then the urine will be
    negative, especially for alcohol, but for narcotics, I think
    that if they use it within a 24-hour period of time prior to
    the test that the urine will be positive. But the urine is not
    universally positive. And so we depend upon another tool. In
    West Virginia, we are using a tool that we call SBIRT. There
    are other areas. People in Chicago, Dr. Ira Chasnoff and his
    people are using the Five Piece Plus model, which is
    trademarked and so forth, so it is expensive.
        So we use the SBIRT model, and there are people who train
    others to use this screening tool because the questions have to
    be asked in a specific way in order to get the answers. And so
    once you have screened them and you realize that they are
    positive, then we hope that we can get them into addiction
    counseling, and I have found looking at the programs that we
    have had in place now for the last 2 years or so, that
    addiction counseling and rehabilitation using behavioral
    medicine specialists seems to be the way to go because
    pregnancy is a unique opportunity, I think, to address
    addiction, and we find, I believe, that there is a very
    positive motivating force that occurs when you are pregnant
    because a woman really wants to deliver a healthy baby, believe
    it or not.
        And so I have found that if we can intervene early in
    pregnancy, that throughout that pregnancy we might be able to
    have some behavior modification, and if not necessarily take
    them off the drug completely because sometimes that might be
    dangerous for the life of the fetus, but at least reduce their
    dependence upon the substance, hopefully using buprenorphine.
    Methadone has been a barrier because the problem is that we
    have now two people taking care of the patient. You have the
    methadone clinics, which are prescribing the medication to the
    mom, and sometimes they actually increase the amount of
    methadone that they are using throughout pregnancy rather than
    decreasing it.
        So we like the conversion method where whatever opioid they
    are using gets converted to buprenorphine or Subutex. We can
    then control that mom a little bit more closely. We can wean
    her off the Subutex during pregnancy and reduce the amount of
    drug the baby is exposed to and hopefully reduce their length
    of stay. They are still probably going to withdraw at the end
    but the withdrawal period will be much shorter than the average
    of 16 or 20 days, whatever it is, and reduce the cost of stay
    and also improve the health and the welfare of both mom and
    baby as they go home.
        Mr. McKinley. Thank you very much. I yield back my time.
        Mr. Murphy. Thank you. Mr. Tonko, you are recognized for 5
    minutes.
        Mr. Tonko. Thank you, Mr. Chair, and welcome to the
    panelists. Thank you for bringing your intellect and your
    passion to the table. It is most helpful.
        In October of last year, the Atlantic magazine published an
    article titled ``The New Heroin Epidemic,'' which looked at a
    number of challenges facing addicts in West Virginia. I would
    like to enter this article into the record, Mr. Chair.
        Mr. Murphy. Without objection.
        [The article has been retained in committee files and can
    be found at: http://docs.house.gov/meetings/if/if02/20150326/
    103254/hhrg-114-if02-20150326-sd008.pdf.]
        Mr. Tonko. Thank you.
        The article discusses the challenges faced by opiate
    addicts seeking treatment including lack of doctors, poor
    reimbursement rates by Medicaid, and long waiting lists for
    some that are seeking treatment. I would like to discuss these
    barriers with the panel and ask whether sufficient resources
    currently exist to get treatment to those who need it.
        Dr. Maxwell, you have tremendous experience caring for
    patients in the State of West Virginia. Do those wishing to get
    help for opioid addiction have sufficient access to effective
    treatment programs, particularly those in rural areas where
    addiction specialists might be hard to find?
        Dr. Maxwell. Well, to be honest, sir, I don't have as much
    experience as you might think with addiction--people who are
    addicted to opiates. I really am a newborn intensivist, and I
    take care of the babies that are a product of those addicted
    moms.
        But having said that, I am on the Governor's Advisory
    Council for Substance Abuse in West Virginia. Governor Tomlin
    established this probably 3, 4, years ago now, and we have an
    advisory council that oversees the work of task forces within
    the State. We have split the State into six different areas,
    and each area, each of those six areas has a task force, and
    the task force has meetings every month or bimonthly at the
    community level where they get information from the people. And
    then they bring that to the advisory council and we meet once
    or twice a year to collate all that information in terms of
    access to care, who is getting what and so forth, and where
    treatment centers are needed, et cetera, and we have had some
    success. The first year we had $7 million to spend, and we
    advised the Governor how to spend that money by identifying
    areas within the State that needed a treatment center, or
    because I am biased and it was for women and pregnant women
    treatment center, so we are working on that problem. I don't
    have all that information with me but I can get it to you.
        Mr. Tonko. Thank you. That would be most helpful.
        And Dr. Banta-Green, a similar question. What are the
    resource challenges facing those who wish to find effective
    treatment for addictions, and are there research challenges in
    your State of Washington or the surrounding States like Idaho
    and Oregon? What are you seeing out there as a person so deeply
    invested in this arena?
        Mr. Banta-Green. Thank you for the question. So just to be
    clear, methadone maintenance is done in large treatment
    facilities, generally in larger cities, and there actually is
    demand for that. We actually at one of our large facilities had
    afternoon dosing last year because there was such demand. But
    in terms of buprenorphine, which is really important, because
    as opiate addiction has spread across the states into more
    rural areas, methadone clinics aren't going to be able to serve
    all those places. You can't go and dose 6 days a week. You need
    something like buprenorphine. It is much easier to access from
    a geographic perspective.
        But Dr. Roger Rosenblatt at the University of Washington
    recently published literature on this and found that many, many
    of the rural communities do not even have a single Suboxone
    provider, and what I think it is important to understand is
    that there is the geographic barrier in terms of many
    communities don't even have a Suboxone provider. My
    understanding, and he has done research with those physicians,
    particularly those who have already been trained and waivered
    by DEA to provide buprenorphine for addiction treatment, most
    still don't ever prescribe, and the reason they do not
    prescribe is that they are not getting adequate reimbursement
    is one piece of it, but there are inadequate addiction
    counseling services in their communities and also they do not
    want to be the only doctor prescribing, and in fact, they
    should not be the only doctor prescribing. It is not
    appropriate to have a single provider in a community doing
    addiction treatment. So those are some of the barriers that are
    faced in terms of having enough physicians step up to prescribe
    at the same time is really important. There are reimbursement
    issues and then there are also those geographic issues as well.
        Mr. Tonko. So is it basically a function of the trained,
    talented, skilled set of people or is it a function of
    resources made available beyond reimbursement rate levels?
        Mr. Banta-Green. I think in the very short term--and I
    think what is really important is, we need to understand that
    buprenorphine as a medication is overdose prevention. It is
    long-term overdose prevention. Naloxone is 90-minute overdose
    prevention. Buprenorphine is potentially many, many years'
    worth of overdose prevention. So there are clearly
    reimbursement issues but there are also many providers with
    very poor training in addiction. They know very little about
    addiction. They are very uncomfortable with it just as they are
    very uncomfortable with prescribing opioids, which they also
    have very poor training in, which are pretty important issues,
    given what we are talking about, that there is not adequate
    training.
        Mr. Tonko. Especially with it being a gateway to the
    addiction, heroin addiction.
        I thank you very much. I see my time is exhausted, and I
    yield back, Mr. Chair.
        Mr. Murphy. They called votes. We are going to try and get
    through another one. Mr. Griffith, you are recognized for 5
    minutes.
        Mr. Griffith. Thank you, Mr. Chairman. I appreciate that
    very much.
        Dr. Melton, we have been talking some about naloxone, and I
    know there are going to be folks watching this at home today
    and who will be watching it at home over the next week or so as
    the C-SPAN replays it. Can you explain to the public what
    naloxone does in the case of a heroin or opioid overdose?
        Ms. Melton. Sure. In simple terms, naloxone is an opioid
    antagonistic or a blocker, and so when naloxone is administered
    either intranasally, IV, or intramuscularly, it goes to the
    receptors in the brain to block opioid receptors. And so it
    will kick off heroin, other opioids immediately, and by doing
    that, it reverses respiratory depression and other central
    nervous system depression that leads to death. So what happens
    is the patient goes into nearly immediate withdrawal, but
    unfortunately, naloxone only lasts for a short period of time
    and so often additional dosing is needed, especially with
    methadone overdoses, which has a very long activity in the
    body.
        Mr. Griffith. So it is not to help somebody who has got a
    problem continue their problem but it is to help them if they
    have had an overdose so that they don't die. Isn't that
    correct?
        Ms. Melton. Absolutely right. It should never be considered
    that people will use naloxone so that they can have a higher
    dose of heroin. You ask any addict if they want to go into
    immediate withdrawal, and they will tell you it is their worst
    nightmare.
        Mr. Griffith. I recently wrote a bipartisan letter with 22
    of my colleagues here in the House calling on the
    Administration to develop practices for naloxone use and
    reprogram existing funds to provide naloxone to medical
    providers. I think that is a good idea. You have mentioned here
    in your earlier testimony Senator Kaine's bill that provides
    Good Samaritans with some immunity from liability unless they
    are acting grossly negligently or maliciously. What else do you
    think that we can do to promote this from a congressional
    standpoint and make sure that the public is aware of it?
        Ms. Melton. Well, I think one issue is, I think we are
    getting the awareness going across the country now but access
    to it, patients being able to afford it is a difficulty. It
    really needs to be mandated coverage by insurance companies so
    we are able to access it easily at the pharmacy. Virginia's new
    legislation will allow pharmacists to, through a collaborative
    practice agreement, write prescriptions for patients that come
    in and ask for it and train them on the spot, which I think is
    a huge step forward, so that will increase access, but again,
    the payment issues are a barrier.
        Mr. Griffith. And nobody is accusing the Virginia
    legislature of being soft on drugs or being liberal in this
    area, wouldn't you agree?
        Ms. Melton. I agree.
        Mr. Griffith. Yes, ma'am.
        Now, in my district, our region of southwest Virginia
    shares borders with four other States: West Virginia, Kentucky,
    Tennessee and North Carolina, two of which are represented here
    today as well. This makes it easy for people to cross State
    lines to doctor-shop and gather multiple prescriptions and from
    multiple pharmacies to get large amounts of prescription
    painkillers. What effect has this doctor-shopping had on our
    problem and how might we address it? And I will start with you,
    Dr. Melton, but the folks from Tennessee and West Virginia are
    welcome to chime in.
        Ms. Melton. OK. So as I stated in my testimony, Virginia,
    Tennessee, West Virginia and the other border States will soon
    be participating in the Interconnect, which allows prescription
    drug monitoring programs to connect across States lines, so
    when I have a patient that comes in, I automatically run a
    query, let us say from Virginia I can access 15 different
    States immediately and see if they have had any prescriptions
    filled in other States. It has been amazing to see how we are
    able to identify doctor shoppers and identify them as a
    potential for addiction and get them into treatment.
        Mr. Griffith. And I would have to say for those that don't
    the area well, you would have to work at it but you could
    actually hit all five states in a single day if you really
    organized.
        Do either of the folks want to add something?
        Mr. Brason. From North Carolina, obviously we are along
    Virginia and Tennessee and so forth, and we have the same
    program to where prescribers can access each individual State
    so that they can check the patient's history to make sure that
    they are not crossing those lines.
        Mr. Griffith. Very good.
        Dr. Maxwell?
        Dr. Maxwell. From West Virginia, yes, we have recently
    passed legislation for pharmaceutical tracking, et cetera.
        Just one point is that an unintended consequence from
    cracking down on the pill mills or whatever may be responsible
    for the increase in heroin use that we are seeing now because
    the patients that are coming in are not on oxycodone or
    hydrocodone or Percocet or any of these drugs any longer but
    they are on heroin, which is more easily available, and that
    might have been an unintended consequence.
        Mr. Griffith. Yes, sir. I appreciate it very much.
        I see my time is up, Mr. Chairman. I thank you and yield
    back, and thank all the witnesses for being here today.
        Mr. Murphy. Thank you, Mr. Griffith.
        We are going to take a brief break to have votes. We should
    be back here, let us aim for around 12:15, and we will continue
    on with our questions, and I thank the panel for waiting.
        [Recess.]
        Mr. Murphy. All right. We reconvene this hearing of
    Oversight and Investigations on substance abuse and addiction.
        I am now going to recognize Mr. Mullin of Oklahoma for 5
    minutes.
        Mr. Mullin. Thank you, Mr. Chairman, and Mike, thank you
    again for taking the time to come up here and give your
    professional opinion.
        Earlier this year, the Oklahoma Department of Health
    released a report that showed that heroin deaths in Oklahoma
    had increased tenfold in the past 5 years, and between 2007 and
    2014, treatment centers in Tulsa County saw a 99 percent
    increase of those being admitted for heroin and prescription
    drug use. That is astounding, and one thing that we constantly
    hear about is where are the drugs coming from, and Mike, being
    that you have worked--or Corporal Griffin, sorry--being that
    you have worked undercover for literally 12 years, you continue
    to arrest people in Tulsa and some places even farther than
    that, but where does the barrier happen? What are your
    limitations?
        Mr. Griffin. So the barrier, or the goal, of course, in all
    our drug investigations is, like I said earlier, we are not
    targeting individuals addicted to drugs. We are going after the
    people that are hurting other people by supplying drugs and
    ruining those people's lives. So when you think of
    methamphetamine, cocaine, heroin, things like that, you are
    always working up the ladder, so to speak, to get to the
    biggest drug dealer we can find and almost always that leads us
    back to the U.S. border with Mexico. Different from that is
    prescription drugs where in those situations--I hate to use the
    word ``dealer'' but the dealer in that situation is a doctor or
    a pharmacist. Ninety-nine-plus percent of those people are law-
    abiding people doing the right thing for all the right reasons.
    A very small percentage of them may be taking advantage of the
    situation.
        Even in those situations where it is maybe a rogue doctor
    or pharmacist, the laws that are set up in Oklahoma make it
    almost impossible for us to pursue them through the law
    enforcement for the way that we do cases, so that is part of
    why we have so few people dedicated to that and so many
    dedicated to the other major drugs of addiction.
        Mr. Mullin. And Corporal Griffin, your job is to catch the
    bad guy, and once you catch the first person, sometimes that is
    the user, maybe it is the seller, but you try tracking it back
    as far as you can go?
        Mr. Griffin. Yes, sir.
        Mr. Mullin. Are you being successful at that?
        Mr. Griffin. We are very successful at it. We have a great
    relationship with other law enforcement agencies in the area to
    include DEA and FBI. We are constantly working on cases that
    cross State boundaries. We are working a very big case right
    now. Hopefully we will really start moving further down the
    road within the next week or two, and we already know that that
    case is an international case that has been operating for a
    long, long time, not only in the United States but in Oklahoma,
    and that is a case we will work all the way into Mexico with
    the help of federal law enforcement agencies.
        But even if we were to say we were successful in that
    operation and get the people that are in Oklahoma and Texas and
    other places that are making millions of dollars from their
    illegal distribution of methamphetamine, cocaine, even at that
    level and we take them off, the drug-trafficking organization
    is going to replace them and before long they will be right
    back up and running because it is so easy to smuggle those
    drugs into our country that if we don't address that issue, I
    am a hamster on a wheel and just keep spinning.
        Mr. Mullin. Mr. Fitz, Corporal Griffin, his team, they make
    the arrest. The paperwork ends up on your desk. What happens at
    that point?
        Mr. Fitz. Well, again, it depends on the type of case. In
    my office, we do not negotiate--we don't dismiss the charges.
    We plead to all the charges, and we basically have the
    philosophy, get clean or get prison, and we have a big meth
    problem in addition to obviously things such as heroin and
    cocaine and so forth but our biggest problem actually is
    methamphetamine, and what we----
        Mr. Mullin. Corporal Griffin, you have a tremendous amount
    of knowledge about meth too.
        Mr. Griffin. Methamphetamine is just the biggest drug
    facing Oklahoma right now.
        Mr. Fitz. So what we have, I think something that actually
    our treatment providers are very much--they subscribe to it and
    they buy into it. What we do is, we indicate to the defendant
    that our guidelines on meth, for instance, are fairly high, and
    we indicate to them that they plead as charged to everything
    and they agree that they will go into a treatment program.
    Usually is a yearlong treatment court, family treatment court,
    adult treatment court, and if they get clean, they never go to
    prison, but if they don't, then they go to prison for a
    substantial period of time, 4, 5, 6 years.
        Mr. Mullin. Corporal Griffin made a statement right at the
    end of it, and Mr. Chairman, if you would indulge me just an
    extra minute? Corporal Griffin made a statement that he feels
    like he is a hamster on the wheel. Although he believes in the
    process, it revolves over and over again. Do you see that same
    thing happening in the court system? I mean, do you see the
    same people coming back over and over again?
        Mr. Fitz. There is a large percentage, but again, that is
    just the tragic reality of drug activity is not only the users
    but also the dealers because oftentimes the penalties are quite
    lenient. And let me just comment on that too. We see cartel
    activity in Michigan also on these drugs. It is a very real
    problem. And I agree with him that I think it is very important
    to try to address this problem on the border but maybe let me
    also mention something I think that is important to keep in
    mind when dealing with these type of issues is that I look at
    drug activity, and I know many of my colleagues do as well, it
    is like cutting the grass. You need to remember that grass will
    never stop growing, drugs will not ever stop coming in, but if
    you stop cutting the grass, your lawn is going to get out of
    control. If we stop vigorous enforcement, we are going to see
    things far worse than what we even see right now. And maybe
    just one other analogy I would give to you also. Sometimes you
    do hear that we can't arrest our way out of the problem, and I
    do agree with that, that arresting is not the only solution. It
    has to be a multifaceted approach to it. But that doesn't mean
    we stop arresting people that do bad things such as drug
    dealing, murder. We are never going to stop murder, we are
    never going to stop home invasions, but we continue to address
    the problem, and again, because it does have the churn effect,
    it does have justice, it does involve public safety as well.
        Mr. Mullin. Corporal Griffin, Mr. Fitz, thank you so much.
    Thank you, Mr. Chairman.
        Mr. Murphy. Thank you. The gentleman yields back. I now
    recognize Ms. Brooks for 5 minutes.
        Mrs. Brooks. Thank you, Mr. Chairman, for holding this
    hearing. I have to say, I wish that we could actually spend
    hours upon hours discussing this critical problem.
        I have actually been a defense attorney. I have been a
    United States attorney. I was at our State's community college
    and have dealt with individuals with addiction but nothing
    really touched me as much as when I went and visited the Hope
    Academy and saw a recovery high school and realized that that
    is the type of program--because I have been involved in the
    take-downs of the big cartels and organizations in our
    community in the southern district of Indiana, but we have to
    stop it. There is always going to be a supply but I want to
    focus a bit on the demand and what we are doing on the demand
    side, and I really appreciate you being here, Ms. Gardner, and
    want to ask about those recovery supports that are so important
    and what are some of the things--I would like you to talk a bit
    more about how the high school works and about what--because
    there are only 35 in the country but yet you have had really
    very wonderful results. You have alumni who are involved.
    Fairbanks Hospital has brought the community together, but I
    have to tell you, when I sat in the circle with kids who had
    the support group, and when a young girl said to the group she
    was turning 17 the next day and it was her first birthday in 4
    years that she would be sober, it broke my heart.
        And can you please talk with us about your kids and about
    what are the recovery supports and how should we at the federal
    level be supporting recovery efforts?
        Ms. Gardner. So a little bit about the school. We are a
    high school so we are 9th through 12th grade, public education,
    so it is a tuition-free school. It looks a little different at
    our school. They start a little later. What we have in the
    school is called recovery coaches. So, it is a dual recovery.
    It is about gaining better grades so that they can go on to
    higher education but it is also about helping them to stay in
    long-term recovery. Sometimes that is a daily battle. Some kids
    have been there that have been there, that have 6 months to a
    year sober. Some have 30 days. They come to us from treatment
    centers. They come to us from private therapists. They come to
    us from jails, from probation. So we are dealing with a wide
    variety of young people. But the whole goal is to help them be
    in a safe, sober environment and to be able to go on to
    graduate and be successful.
        We have done lots of research with our students in the
    sense of what works for different students who have different
    drugs of choice, but what we know is, is that if we can help
    them sustain daily recovery and we look at long-term recovery
    as staying abstinence free, doing 12 steps or doing other types
    of recovery supports, that we know there is a chance to move on
    and to have their brains as their brains are developing become
    more salient and more ability to learn and make better choices
    and develop some positive coping skills, the better the success
    is going to be.
        Mrs. Brooks. Can you share with us what you think we at the
    federal level can do to help provide support for programs like
    yours?
        Ms. Gardner. So we have talked a lot about law enforcement,
    we have talked a lot about medication. Access to treatment is a
    problem across the country. The Affordable Care Act has allowed
    the ability for more people to get it. My opinion in Indiana
    currently, our young people don't get to stay long enough in
    treatment. We look at young people like we look at adults.
    Their brains haven't developed the ability to make informed
    decisions and so you are looking at a young person who is
    addicted but also having to be an adolescent and help them grow
    with their development. They need longer times away from those
    people, places and things, and their ability to access recovery
    supports, be it schools, be it things within a traditional
    school, be it long-term aftercare kinds of programs, which
    aren't funded.
        Mrs. Brooks. Thank you for that.
        Focusing and moving a bit to adults, I do want to ask Mr.
    Fitz because Ms. Gardner talked about treatment and the length
    of treatment. Can you give me your thoughts on the benefits of
    substance abuse treatment courts in our criminal justice system
    and what you know about them in my brief time remaining? I have
    been a proponent but I would like to hear what you in your role
    believe.
        Mr. Fitz. In my jurisdiction, we happen to have multiple
    specialty courts. I think it is five or six of them, and we do
    have a fair number of them in the State of Michigan. So my
    response, I guess, would be not just from my perspective but
    from other prosecutors. Prosecutors generally feel that there
    is a need for more treatment because obviously if we can get
    someone clean, they are less likely to come back into the
    system, and that makes our job easier and makes the public
    safer.
        But again, it is a balance because we recognize that if
    they don't get clean, that we need to continue to protect the
    public because even drug addicts sometimes do very unfortunate
    things--child abuse, sexual abuse, thefts, things of that sort,
    crimes of violence. So it invasive species balance but
    prosecutors do see a need for more treatment.
        Mrs. Brooks. Thank you. I yield back.
        Mr. Murphy. Thank you, Ms. Brooks.
        Ms. DeGette, you have a follow-up question?
        Ms. DeGette. I will follow up on what Ms. Brooks was just
    asking Mr. Fitz.
        We have some drug courts in Denver too and actually the
    Denver district attorney is a good friend of mine, Mitch
    Morrissey. I don't know if you know him. But one thing----
        Mr. Fitz. I don't.
        Ms. DeGette. But one thing that drug courts do is, they
    will order people to go--I mean, one reason we have drug courts
    is exactly the problem that you talked about I think in
    response to Mr. Mullin's question. You see so much recidivism
    with drug abusers, right?
        Mr. Fitz. Yes.
        Ms. DeGette. I mean, it is a terrible problem. So one
    reason they have started drug courts is so that we can find a
    way to do the different kinds of treatment that all of the
    experts here talked--every single expert said it is not just a
    one-shot deal with people who get addicted to these opiates.
    Since it changes your brain, different people need types of
    treatment. But something that is unique about drug courts is
    that they are trying to send these offenders to programs. They
    are not just saying to folks, OK, now go get clean. I mean,
    they send them into programs, right?
        Mr. Fitz. Really, what especially courts are doing, they
    are doing what prosecutors have lawyers felt that traditional
    probation should be, which is very intensive including----
        Ms. DeGette. Right.
        Mr. Fitz [continuing]. Daily drug testing, the things they
    need to get on the straight and narrow, so to speak.
        Ms. DeGette. Right, and that includes programs, which they
    may be given these medications, right?
        Mr. Fitz. Again, there is a split of opinion on that in my
    state. In our jurisdiction, they don't focus on those, and
    again, I am not educated enough on that to give you the
    expertise as to whether that is good or bad, but I will say
    that, for instance, Monroe County, one of our counties that I
    suggested to one of your staffers would be a good county in
    Michigan to talk to, Bill Nichols, the prosecutor, they do use
    those Suboxone----
        Ms. DeGette. Dr. Banta-Green, you are nodding your head
    here. Did you want to talk about that?
        Mr. Banta-Green. Sure. So most drug courts do not allow
    people on medication-assisted treatment or in fact taper them
    off. I think it would be actually great to do the opposite,
    which is to allow all drug courts in fact to require that they
    allow some type of medication-assisted treatment with methadone
    or buprenorphine, and as I talked about that doctor shortage in
    rural areas, part of the thing they need are supports. So if
    they had the support of a court that they knew had criminal
    sanctions over this person, right, so they are concerned about
    having all these addicted patients they don't feel like have
    much control over, partnering with the court----
        Ms. DeGette. Right.
        Mr. Banta-Green [continuing]. Would be a nice partnership
    and maybe a win-win both for the community in terms of having a
    lot less crime----
        Ms. DeGette. And you might see less recidivism too.
        Mr. Banta-Green. Absolutely.
        Ms. DeGette. Just one more thing, Mr. Chairman. The
    Department of Justice has actually said in its discretionary
    grant program for drug courts that drug courts need to use
    these medication-assisted programs as part of it because it
    really is medicine, not drug addiction, and I guess I would
    like to put that into the record, Mr. Chairman.
        Mr. Murphy. Sure. Without objection.
        [The information has been retained in committee files and
    can be found at: http://docs.house.gov/meetings/IF/IF02/
    20150326/103254/HHRG-114-IF02-20150326-SD007.pdf.]
        Ms. DeGette. And let me just say, I really appreciate this
    panel coming. Congresswoman Brooks and I were saying during the
    vote how extremely helpful we thought all of your testimony
    was, so thank you, and I yield back.
        Mr. Murphy. Thank you. The gentlelady yields back.
        I know that today HHS announced they are going to put $113
    million toward addressing the opioid epidemic focusing on
    providing training, education, resources including updated
    prescriber guidelines, assist health professionals regarding
    the over-prescribing, increasing use of naloxone as well as
    continuing to support the development and the distribution of
    the lifesaving drug, and expanding the use of medication-
    assisted treatment, the MAT program. I think this is good news.
    We will want to work with them.
        We had a recent hearing where the Government Accountability
    Office had told us that federal agencies were not working well
    together, 112 programs that deal with mental illness. But I
    think Secretary Burwell is really trying to make some changes
    in this, and we applaud that, so we will be looking forward to
    seeing how that does.
        But I want to ask one follow-up question. On that first
    issue of dealing with healthcare professionals who over-
    prescribe, some doctors have told me that now as they are rated
    by patients, one of the things they are rated on is, you know,
    the comfort level and managing pain, and of course, a physician
    who is looking to boost their ratings doesn't want that patient
    to leave their office in pain. So there is an incentive there,
    again, one of these bizarre incentives we have to over-
    prescribe. Any of you have any comments on that and how we deal
    with that aspect of things? Mr. Brason.
        Mr. Brason. Yes. We addressed that with the prescribing
    populations that we have taught and trained on managing pain
    and appropriate prescribing is instituting best practice
    methods for doing that frontend assessment to determine what
    kind of risk do we have here: do you have a biological risk, do
    you have a cultural risk, do you have an environmental risk.
    and if those are answered, then you know how to appropriately
    prescribe or put in the safeguards with the urine screens and
    pill counts and so forth.
        And then coupled with that, the FDA has been approving
    abuse-deterrent formulations to make them available to
    individuals so that they can't crush and they can't snort and
    they can't inject. So when you are combining that federal level
    work with the local prescriber, you can still prescribe but
    then it is a much safer product.
        The problem we have is the coverage in order to pay for
    that, you know, that obviously that probably boosts the price
    of the drug a little more so while the copay for this is $5,
    the copay for this is $50, the patient is going to want the $5.
    It is a generic that is abusable, and then we have the issues,
    and I was recently with a doctor in southwest Virginia, a great
    pain management facility, and I said are you prescribing the
    abuse-deterrent formulations, and she says I can't get
    coverage, you know, so those are some of the areas that, you
    know, we have got one end doing what they want to do and on the
    other end the prescribers doing what they want to do, but the
    people in the middle that cover this and pay for this, you
    know, are problematic.
        But the prescribers for the most part are willing to do
    best practice as long as they continue to treat and then have
    the mechanism to help somebody who needs the help.
        Mr. Murphy. Anybody else have a follow-up statement you
    want to make on that point?
        Dr. Banta-Green.
        Mr. Banta-Green. I would just mention so at the University
    of Washington in terms of trying to limit opioid use and treat
    pain well, and again, as you mentioned, the JCAHO is actually
    focused on pain as the fifth vital sign, and we think that is
    part of what has led a lot of visits. It is easy to quickly
    treat pain with an opiate, and what we are seeing is that, as I
    mentioned earlier, it may lead to a lot of dysfunction, but if
    pain is your measure, if symptom relief is your pure measure,
    you are in trouble, because what we really care about is
    functioning, and that is really the idea that we are moving
    towards. There is a nice computer-based support for physicians
    called the Pain Tracker that among other things really helps
    that patient focus every visit on what is their functioning,
    not just their pain level, but really, what is their
    functioning.
        Mr. Murphy. Good point. I know I was once on a
    congressional visit to Iraq, and unfortunately, I was in a
    rollover accident and hurt my spine and a little bit paralyzed
    for a while, but I know--and part of this is military medicine,
    patch them up, ship them out, but I know coming back from
    there, I was on OxyContin, Percocet, Tylenol, which is the
    mildest one, and fentanyl patches, and you are that kind of a
    cocktail and you don't know which way is up, and for myself, I
    said I am not doing this anymore. I ripped off the fentanyl
    patch and did everything. It was not a pleasant experience. I
    can't imagine what it is like for someone who has been taking
    those kind of things for months or years.
        So as a person who has dealt with folks with substance
    abuse, as a person who has lived with someone with substance
    abuse, as someone who has treated and worked with infants in
    newborn intensive care units, I want to thank you all for your
    work. Some of you like Corporal Griffin putting your life on
    the line, thank you for your service. Mr. Fitz, thank you for
    doing those things at a prosecutor level. Ms. Gardner, great
    stories of what is happening in the school. Keep up the great
    work. I understand one of your graduates is in medical school?
        Ms. Gardner. Yes, sir.
        Mr. Murphy. That is awesome.
        Ms. Gardner. Thank you.
        Mr. Murphy. We wish him the best. And all of you, thank you
    for your front line work.
        We will be having other things on this. You heard Ms.
    DeGette talk about we will want to be looking at state policies
    and federal policies. Please don't let be your last contact.
    You were brought here by some distinguished Members of Congress
    who believe in a lot of what you do. Keep that conversation
    going, and encourage your colleagues from around the country
    too. We want to know what to do here because this deadly
    epidemic is something that we have to address, and we look
    forward to hearing your expert opinions on this.
        Thank you all so much. Have a wonderful Easter. And it is
    now adjourned.
        [Whereupon, at 12:40 p.m., the subcommittee was adjourned.]
        [Material submitted for inclusion in the record follows:]

                 Prepared statement of Hon. Frank Pallone, Jr.

        Mr. Chairman, thank you for convening this hearing today on
    this important issue.
        Prescription drug abuse is an epidemic in the United
    States. We see its effects throughout the country in all of our
    districts. In New Jersey, we have seen the rate of drug
    overdose deaths nearly double in the last ten years.
        I want to use today's hearing to understand what we can do
    to combat this epidemic. We must work together - at the local,
    state, and federal levels - to expand effective prevention and
    treatment efforts for opioid abuse.
        We need to focus on what works. Research tell us that
    medication-assisted treatment combined with counseling is the
    most effective method of treating opioid addictions. Yet
    throughout the country, many treatment facilities continue to
    be based in an abstinence-only model that prohibits the use of
    medication. We need to understand why that is the case and how
    we can increase access to medication-assisted treatment.
        I want to highlight some of the work being done in New
    Jersey to address the opioid addiction epidemic. In 2013, the
    New Jersey legislature passed a law to expand access to
    naloxone, a life-saving medication that reverses the effects of
    a drug overdose. Nearly 30 states now have such laws.
        In my district, Rutgers University was one of the first
    colleges to offer a residential program for the growing number
    of students with substance use disorders. In 1988, the
    University first established the Collegiate Recovery Community
    to provide a safe place for students in recovery. There are now
    over twenty such programs across the nation.
        Just outside my district, the Raymond J. Lesniak Recovery
    High School, New Jersey's first and only public recovery high
    school, opened earlier this year. It serves students who wish
    to recover from their substance use disorders in a safe
    environment.
        Here in Congress, we took significant steps to expand
    access to health care for all Americans, including those with
    substance use disorders, with the passage of the Affordable
    Care Act. For many addicts, the lack of insurance or the cost
    of treatment presents an insurmountable barrier to receive the
    help they need. The Affordable Care Act addresses these
    problems by expanding insurance coverage and requiring that
    insurance cover the cost of substance abuse services. This will
    mean that millions of people will have access to the tools they
    need to break their addictions.
        I also want to speak for a moment in support of the
    reauthorization of the National All Schedules Prescription
    Electronic Reporting Act - or NASPER. This legislation helps
    states set up prescription drug monitoring programs in order to
    combat prescription drug abuse and supports interoperability of
    state programs. It is critical that we continue support for
    this program through federal funding.
        I want to thank all the witnesses for appearing before us
    today. I'm eager to hear about the work you're doing to combat
    this epidemic.I yield the remainder of my time to Rep. Kennedy.
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