[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


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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:]
    
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    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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