[House Hearing, 114 Congress]
[From the U.S. Government Publishing Office]
EXAMINING THE GROWING PROBLEMS OF
PRESCRIPTION DRUG AND HEROIN ABUSE: STATE AND LOCAL PERSPECTIVES
=======================================================================
HEARING
BEFORE THE
SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS
OF THE
COMMITTEE ON ENERGY AND COMMERCE
HOUSE OF REPRESEN7TATIVES
ONE HUNDRED FOURTEENTH CONGRESS
FIRST SESSION
__________
MARCH 26, 2015
__________
Serial No. 114-27
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Printed for the use of the Committee on Energy and Commerce
energycommerce.house.gov
______
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COMMITTEE ON ENERGY AND COMMERCE
FRED UPTON, Michigan
Chairman
JOE BARTON, Texas FRANK PALLONE, Jr., New Jersey
Chairman Emeritus Ranking Member
ED WHITFIELD, Kentucky BOBBY L. RUSH, Illinois
JOHN SHIMKUS, Illinois ANNA G. ESHOO, California
JOSEPH R. PITTS, Pennsylvania ELIOT L. ENGEL, New York
GREG WALDEN, Oregon GENE GREEN, Texas
TIM MURPHY, Pennsylvania DIANA DeGETTE, Colorado
MICHAEL C. BURGESS, Texas LOIS CAPPS, California
MARSHA BLACKBURN, Tennessee MICHAEL F. DOYLE, Pennsylvania
Vice Chairman JANICE D. SCHAKOWSKY, Illinois
STEVE SCALISE, Louisiana G.K. BUTTERFIELD, North Carolina
ROBERT E. LATTA, Ohio DORIS O. MATSUI, California
CATHY McMORRIS RODGERS, Washington KATHY CASTOR, Florida
GREGG HARPER, Mississippi JOHN P. SARBANES, Maryland
LEONARD LANCE, New Jersey JERRY McNERNEY, California
BRETT GUTHRIE, Kentucky PETER WELCH, Vermont
PETE OLSON, Texas BEN RAY LUJAN, New Mexico
DAVID B. McKINLEY, West Virginia PAUL TONKO, New York
MIKE POMPEO, Kansas JOHN A. YARMUTH, Kentucky
ADAM KINZINGER, Illinois YVETTE D. CLARKE, New York
H. MORGAN GRIFFITH, Virginia DAVID LOEBSACK, Iowa
GUS M. BILIRAKIS, Florida KURT SCHRADER, Oregon
BILL JOHNSON, Ohio JOSEPH P. KENNEDY, III,
BILLY LONG, Missouri Massachusetts
RENEE L. ELLMERS, North Carolina TONY CARDENAS, California
LARRY BUCSHON, Indiana
BILL FLORES, Texas
SUSAN W. BROOKS, Indiana
MARKWAYNE MULLIN, Oklahoma
RICHARD HUDSON, North Carolina
CHRIS COLLINS, New York
KEVIN CRAMER, North Dakota
Subcommittee on Oversight and Investigations
TIM MURPHY, Pennsylvania
Chairman
DAVID B. McKINLEY, West Virginia DIANA DeGETTE, Colorado
Vice Chairman Ranking Member
MICHAEL C. BURGESS, Texas JANICE D. SCHAKOWSKY, Illinois
MARSHA BLACKBURN, Tennessee KATHY CASTOR, Florida
H. MORGAN GRIFFITH, Virginia PAUL TONKO, New York
LARRY BUCSHON, Indiana JOHN A. YARMUTH, Kentucky
BILL FLORES, Texas YVETTE D. CLARKE, New York
SUSAN W. BROOKS, Indiana JOSEPH P. KENNEDY, III,
MARKWAYNE MULLIN, Oklahoma Massachusetts
RICHARD HUDSON, North Carolina GENE GREEN, Texas
CHRIS COLLINS, New York PETER WELCH, Vermont
KEVIN CRAMER, North Dakota FRANK PALLONE, Jr., New Jersey (ex
JOE BARTON, Texas officio)
FRED UPTON, Michigan (ex officio)
C O N T E N T S
----------
Page
Hon. Tim Murphy, a Representative in Congress from the
Commonwealth of Pennsylvania, opening statement................ 1
Prepared statement........................................... 4
Hon. Diana DeGette, a Representative in Congress from the state
of Colorado, opening statement................................. 6
Hon. Fred Upton, a Representative in Congress from the State of
Michigan, opening statement.................................... 8
Prepared statement........................................... 9
Hon. Joseph P. Kennedy, III, a Representative in Congress from
the Commonwealth of Massachusetts, opening statement........... 10
Hon. Frank Pallone, Jr., a Representative in Congress from the
State of New Jersey, prepared statement........................ 101
Witnesses
Fred Wells Brason, II, Executive Director, Project Lazarus,
Moravian Falls, North Carolina................................. 12
Prepared statement........................................... 15
Sarah T. Melton, PharmD, BCPP, BCACP, CGP, FASCP, Associate
Director of Pharmacy Practice, Gatton College of Pharmacy at
East Tennessee State University, Johnson City, Tennessee, and
Chair of the Board of Directors of Onecare of Southwest
Virginia, Bristol, Virginia.................................... 25
Prepared statement........................................... 28
Answers to submitted questions............................... 111
Stefan R. Maxwell, M.D., Associate Professor, Pediatrics, WVU
School of Medicine, MEDNAX Medical Group, Medical Director,
NICU, Women and Children's Hospital, Charleston, West Virginia. 38
Prepared statement........................................... 40
Answers to submitted questions............................... 115
Rachelle Gardner, Chief Operating Officer, Hope Academy,
Indianapolis, Indiana.......................................... 49
Prepared statement........................................... 52
Victor Fitz, Cass County, Michigan, Prosecutor, and President of
the Prosecuting Attorneys Association of Michigan (PAAM),
Cassopolis, Michigan........................................... 54
Prepared statement........................................... 56
Michael Griffin, Narcotics Unit Supervisor--K9 Handler, Special
Investigations Division, Tulsa Police Department, Tulsa,
Oklahoma....................................................... 67
Prepared statement........................................... 69
Caleb Banta-Green, Senior Research Scientist, Alcohol and Drug
Abuse Institute, University of Washington, Seattle, Washington. 80
Prepared statement........................................... 82
Answers to submitted questions............................... 119
Submitted Material
Majority memorandum.............................................. 103
Article entitled, ``The New Heroin Epidemic,'' in The Atlantic,
October 30, 2014, submitted by Mr. Tonko \1\
U.S. Department of Justice announcement, submitted by Ms. DeGette
\2\
----------
\1\ Available at: http://docs.house.gov/meetings/if/if02/
20150326/103254/hhrg-114-if02-20150326-sd008.pdf.
\2\ Available at:http://docs.house.gov/meetings/IF/IF02/20150326/
103254/HHRG-114-IF02-20150326-SD007.pdf
EXAMINING THE GROWING PROBLEMS OF PRESCRIPTION DRUG AND HEROIN ABUSE:
STATE AND LOCAL PERSPECTIVES
----------
THURSDAY, MARCH 26, 2015
House of Representatives,
Subcommittee on Oversight and Investigations,
Committee on Energy and Commerce,
Washington, DC.
The subcommittee met, pursuant to call, at 10:15 a.m., in
room 2123 of the Rayburn House Office Building, Hon. Tim Murphy
(chairman of the subcommittee) presiding.
Present: Representatives Murphy, McKinley, Griffith,
Bucshon, Brooks, Mullin, Hudson, Collins, Upton (ex officio),
DeGette, Schakowsky, Tonko, and Kennedy.
Staff present: Sean Bonyun, Communications Director;
Leighton Brown, Press Assistant; Noelle Clemente, Press
Secretary; Brittany Havens, Legislative Clerk; Charles
Ingebretson, Chief Counsel, Oversight and Investigations; Chris
Santini, Policy Coordinator, Oversight and Investigations; Alan
Slobodin, Deputy Chief Counsel, Oversight; Sam Spector,
Counsel, Oversight; Jeff Carroll, Democratic Staff Director;
Chris Knauer, Democratic Oversight Staff Director; Una Lee,
Democratic Chief Oversight Counsel; Elizabeth Letter,
Democratic Professional Staff Member; and Tim Robinson,
Democratic Chief Counsel.
OPENING STATEMENT OF HON. TIM MURPHY, A REPRESENTATIVE IN
CONGRESS FROM THE COMMONWEALTH OF PENNSYLVANIA
Mr. Murphy. Good morning.
As I call to order this Oversight and Investigations
Subcommittee hearing to examine the growing problem of
prescription drug and heroin abuse, allow me to share a few
quotes from an article in the New York Times, citing the views
of Dr. Hamilton Wright of Ohio. In the article, Dr. Wright is
quoted as saying: ``Of all the nations of the world, America
consumes the most opium, in one form or another. The habit has
this Nation in its grip to an astonishing extent. Our prisons
and our hospitals are full of victims of it, it has robbed ten
thousand business men and women of sense. The drug habit has
spread throughout America until it threatens us with very
serious disaster.''
What is striking about these statements is not the dismal
picture they paint, but rather, that these remarks were
published over 100 years ago in 1911. Back then, of course, we
did not have the scientific or government involvement that we
have today. Back then, there was no National Office of Drug
Control Policy--the ONDCP--and there was no Department of
Health and Human Services, no Substance Abuse and Mental Health
Services Administration, and there was no National Institute on
Drug Abuse. Yet despite all of our science and public health
agencies, and despite the billions of federal dollars devoted
to fighting the opioid problem, the situation is no better than
it was 100 year ago. Indeed, many would say the situation is
far worse.
According to the Centers for Disease Control, in just the
past 3 years alone, the number of heroin overdose deaths in the
United States has tripled. Tripled. And in some parts of the
country, such as the Midwest, heroin overdose death rates have
increased over 900 percent. Every day 120 people die from a
drug overdose. The vast majority of these overdose deaths are
due to prescription opioid medications. That is more than
43,000 deaths last year, or the tragic equivalent of one
jetliner going down every single day.
In 2009, an estimated 13,000 babies were born in the United
States addicted to heroin or prescription opioids. That is
about one opioid-addicted baby every hour of the day, every day
of the week. Please note that this statistic is from 2009,
several years before the CDC announced our country was in the
midst of an overdose epidemic and before the current explosion
of heroin overdose deaths. The number of babies born addicted
to opioids is much worse today. I used to work in a newborn
intensive care unit, and I have watched too many tiny infants
go through withdrawal symptoms. But seeing only one is enough
to break your heart.
Something is desperately wrong with our Nation's response
to the opioid epidemic, and it is quite literally a matter of
life and death that we get honest answers and not remain
misguided in our approach to how we solve this crisis.
Every Member of Congress is seeing the consequence of the
federal government's failure because it touches every community
and every family across America. My own district in
Pennsylvania has seen the terrible consequences of addiction
and death from opiate overdoses, and the problem has only
gotten worse over the past year. In Westmoreland County,
Pennsylvania, the drug overdose death total for 2014 surpassed
that of 2013--a record to that point--by an additional death,
and during that time, the number of accidental deaths caused by
heroin in the county increased by over 30 percent. In 2014,
Allegheny County, where Pittsburgh is, had 281 fatal overdoses
reported, compared to 278 the previous year, and it is climbing
for this year.
No federal agency has a more central role in this ongoing
epidemic than the Department of Health and Human Services. HHS
and its Substance Abuse and Mental Health Services
Administration, otherwise known as SAMHSA, are tasked with
leading our Nation's public health response to opioid and
heroin abuse and addiction. SAMHSA regulates our country's
1,300 opioid maintenance--formerly known as methadone clinics--
and is responsible for certifying the 26,000 physicians who
prescribe the semi-synthetic opioid buprenorphine. According to
testimony provided by SAMHSA before this subcommittee in April
of last year, nearly 1.5 million people were ``treated''--and I
put ``treated'' in quotes--with these opioids in 2012. That is
a five-fold increase in the last 10 years. Now, I might add, I
will not call this treatment. It is addiction maintenance.
Buprenorphine can more safely maintain a person's
dependence by reducing the need for illegal opioid abuse, such
as heroin, and thereby the risk for overdose. But make no
mistake, buprenorphine is a highly potent opioid, which
according to SAMHSA, is 20 to 50 times more potent than
morphine. So it is worth considering that our national strategy
to combat substance abuse is to maintain addiction by either
prescribing or administering a heroin-replacement opioid. When
you consider research from the National Institute on Drug Abuse
documenting that almost everyone who stops taking buprenorphine
relapses to illicit opioid use within a matter of weeks, it is
deeply concerning thatwe don't have the best solutions for
addiction recovery. According to the Drug Enforcement
Administration, when police conduct a prescription drug bust,
the third most frequently seized drug by law enforcement is
buprenorphine--more than methadone, more than morphine, more
than codeine. And unlike clinics that administer methadone,
there are no requirements for buprenorphine clinics to offer or
even discuss non-addictive treatment alternatives with
patients, no requirements to develop treatment plans, no
requirements to protect the public against it being diverted
for illicit use. Meanwhile, the CDC reports that buprenorphine
is the most frequently cited prescription drug in poisonings of
children, accounting for nearly 30 percent of all opioid-
related emergency department visits and 60 percent of emergent
hospitalizations among children.
Worse yet, of opioid-addicted babies who start their
fragile lives being medically detoxified off of opioids, nearly
half of their mothers are on buprenorphine or methadone
maintenance in HHS/SAMHSA-regulated or -certified practices.
This is government-supported addiction. It is not moving
people to sobriety. We should not just focus on the
extraordinary costs of detoxifying babies off of buprenorphine,
but also the profound consequences for these babies whose
entire experience in the womb and after they are born is
dominated by buprenorphine dependence. Further, there are
significant concerns about short- and long-term
neurodevelopmental impacts of opioid exposure in utero. Why is
the government subsidizing this harm?
Despite these problems, HHS and SAMHSA continue to actively
and aggressively promote the use of buprenorphine, yet
noticeably silent on promoting research and innovative measures
with the goal of ending opioid addiction, not simply continuing
addiction through drug maintenance programs of methadone. It
concerns me that HHS and SAMHSA have no practical guidance on
how to get people off of this prescribed opioid when those on
buprenorphine maintenance for substance abuse disorders use
illicit opioids an average of four times a week.
Now, I recognize this morning that HHS announced new plans
and funding to work on this issue, and this committee eagerly
awaits to see the details on how that will play out.
Compounding this crisis is the lack of evidence-based
treatment to end opioid addiction, not merely replace an
illicit drug with a government-sanctioned one. Evidence-based
treatment includes decisions based on scientific studies with
quantitative data, and is distinguished from those relying on
anecdotes and subjective observations.
Only about 10 percent of persons with a substance abuse
disorder will get any form of medical care. Of those who are
lucky enough to get care, only 10 percent of them will get
evidence-based treatment for the disease of addiction. Yet most
medical professionals are not sufficiently trained to diagnose
or treat the disease of addiction, and most providing addiction
care are not medical professionals and are not equipped to
provide the full range of effective treatments.
Now, I believe in recovery. I believe in lives being
restored and every individual living up to their full God-given
potential and doing so drug-free. I desperately want our
federal efforts to work in every community and for every family
that seeks care for addiction disorders. And I know that
working together, at the federal, State, and local level, we
will achieve success. But we have to set our eyes on the goal
of full recovery, not just addiction maintenance. We can do
this, I have no doubt.
We continue our oversight series today by listening to law
enforcement and public health officials who are working at the
on the front lines to protect our communities and our families
in this national epidemic. We are grateful for your service and
for taking the time to be with us today.
[The prepared statement of Mr. Murphy follows:]
Prepared statement of Hon. Tim Murphy
Good morning. As I call to order this Oversight &
Investigations Subcommittee hearing to examine the growing
problem of prescription drug and heroin abuse, allow me to
share a few quotes from an article in the New York Times,
citing the views of a Dr. Hamilton Wright, of Ohio. In the
article, Dr. Wright is quoted as saying: ``Of all the nations
of the world, America consumes the most opium, in one form or
another.''
``The habit has this Nation in its grip to an astonishing
extent. Our prisons and our hospitals are full of victims of
it, it has robbed ten thousand business men [and women] of
sense ....''
``The drug habit has spread throughout America until it
threatens us with very serious disaster.'' What is striking
about these statements is not the dismal picture they paint,
but rather, that these remarks were published over 100 years
ago in 1911.
Back then, of course, we did not have the scientific or
government involvement that we have today. Back then, there was
no National Office of Drug Control Policy (ONDCP); there was no
Department of Health and Human Services (HHS), no Substance
Abuse and Mental Health Services Administration (SAMHSA); and
there was no National Institute on Drug Abuse (NIDA). Yet
despite all of our science and public health agencies, and
despite the billions of federal dollars devoted to fighting the
opioid problem, the situation is no better than it was 100 year
ago. Indeed, the situation is much worse.
According to the Centers for Disease Control (CDC) in just
the past three years alone, the number of heroin overdose
deaths in the United States has tripled. And in some parts of
the country, such as the Midwest, heroin overdose death rates
have increased over 900 percent.
Everyday 120 people die from a drug overdose. The vast
majority of these overdose deaths are due to prescription
opioid medications. That's more than 43,000 deaths last year,
or the equivalent of one jetliner going down every single day.
In 2009, an estimated 13,000 babies were born in the United
States addicted to heroin or prescription opioids. That's about
one opioid-addicted baby every hour of the day, every day of
the week. Please note that this statistic is from 2009, several
years before the CDC announced our country was in the midst of
an overdose epidemic and before the current explosion of heroin
overdose deaths. The number of babies born addicted to opioids
is much worse today. I used to work on a newborn intensive care
unit. I've watched too many tiny infants go through withdrawal
symptoms. But seeing only one is enough is to break your heart.
Something is desperately wrong with our nation's response
to the opioid epidemic, and it is quite literally a matter of
life and death that we get honest answers and not remain
misguided in our approach to how we solve this crisis.
Every member of Congress is seeing the consequence of the
federal government's failure because it touches every
community; every family across America. My own district has
seen the terrible consequences of addiction and death from
opiate overdoses, and the problem has only gotten worse over
the past year. In Westmoreland County, Pennsylvania, the drug
overdose death total for 2014 surpassed that of 2013--a record
to that point--by one additional death. During the same time,
the number of accidental deaths caused by heroin in the county
increased by over 30 percent. In 2014, Allegheny County had 281
fatal overdoses reported, compared to 278 the previous year.
No federal agency has a more central role in this ongoing
epidemic than the Department of Health and Human Services. HHS
and its Substance Abuse and Mental Health Services
Administration (SAMHSA) are tasked with leading our nation's
public health response to opioid and heroin abuse and
addiction. SAMHSA regulates our country's 1,300 opioid
maintenance (formerly known as methadone clinics), and is
responsible for certifying the 26,000 physicians who prescribe
the semi-synthetic opioid buprenorphine. According to testimony
provided by SAMHSA before this Subcommittee in April of last
year, nearly 1.5 million people were ``treated'' with these
opioids in 2012. That is a 5-fold increase in the last ten
years. I do not call this ``treatment.'' It is addiction
maintenance.
Buprenorphine can more safely maintain a person's
dependence by reducing the need for illegal opioid use, such as
heroin, and thereby the risk for overdose. But make no mistake,
buprenorphine is a highly potent opioid, which according to
SAMHSA, is ``20-50 times more potent than morphine.'' So it is
worth considering that our national strategy to combat
substance abuse is to maintain addiction by either prescribing
or administering a heroin-replacement opioid. When you consider
research from the National Institute on Drug Abuse documenting
that almost everyone who stops taking buprenorphine relapses to
illicit opioid use within a matter of weeks, it is deeply
concerning we don't have the best solutions for addiction
recovery.
According to the Drug Enforcement Administration, when
police conduct a prescription drug bust, the 3rd most
frequently seized drug by law enforcement is buprenorphine.
More than methadone. More than morphine. More than codeine. And
unlike clinics that administer methadone, there are no
requirements for buprenorphine clinics to offer or even discuss
non-addictive treatment alternatives with patients. No
requirement to develop treatment plans. No requirements to
protect the public against buprenorphine being diverted for
illicit use.
Meanwhile, the CDC reports that buprenorphine is the most
frequently cited prescription drug in poisonings of children,
accounting for nearly 30% of all opioid-related emergency
department visits and 60% of emergent hospitalizations among
children.
Worse yet, of opioid-addicted babies who start their
fragile lives being medically detoxified off of opioids, nearly
half of their mothers are on buprenorphine or methadone
maintenance in HHS/SAMHSA regulated or certified practices.
This is government-supported addiction. It is not moving people
to sobriety. We should not just focus on the extraordinary
costs of detoxifying babies off of buprenorphine, but also, the
profound consequences for these babies whose entire experience
in the womb and after they are born is dominated by
buprenorphine dependence. Further, there are significant
concerns about short and long term neurodevelopmental impacts
of opioid exposure in utero. Why is the government subsidizing
this harm?
Despite these problems, HHS and SAMHSA continue to actively
and aggressively promote the use of buprenorphine, yet
noticeably silent on promoting research and innovative measures
with the goal of ending opioid addiction, not simply continuing
addiction through drug maintenance programs of methadone or
buprenorphine. It concerns me that HHS and SAMHSA have no
practical guidance on how to get people off of this prescribed
opioid when those on buprenorphine maintenance for substance
abuse disorders use illicit opioids an average of four times a
week.
Compounding this crisis is the lack of evidence-based
treatment to end opioid addiction, not merely replace an
illicit drug with a government sanctioned one. Evidence-based
treatment includes decisions based on scientific studies with
quantitative data, and is distinguished from those relying on
anecdotes and subjective observations. Only about 10 percent of
persons with a substance abuse disorder will get any form of
medical care; of those who are lucky enough to get care, only
10 percent of them will get evidence-based treatment for the
disease of addiction. Yet, most medical professionals are not
sufficiently trained to diagnose or treat the disease of
addiction, and most providing addiction care are not medical
professionals and are not equipped to provide the full range of
effective treatments.
I believe in recovery. I believe in lives being restored
and every individual living up to their full God-given
potential and doing so drug free. I desperately want our
federal efforts to work in every community and for every family
that seeks care for addiction disorders. And I know working
that together, at the federal, state and local level, we will
achieve success. But we have to set our eyes on the goal of
full recovery, not just addiction maintenance. We can do this,
I have no doubt.
We continue our oversight series today by listening to law
enforcement and public health officials who are working at the
on the front lines to protect our communities and our families
in this national epidemic. We are grateful for your service and
for taking the time to be with us today.
Mr. Murphy. And with that, I now recognize Ms. DeGette of
Colorado.
OPENING STATEMENT OF HON. DIANA DEGETTE, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF COLORADO
Ms. DeGette. Thank you very much, Mr. Chairman, for
convening this hearing today.
As you noted, the opioid epidemic is nothing short of a
public health crisis. In 2013, prescription painkillers were
involved in over 16,000 overdose deaths, and heroin was
involved in an additional 8,257 deaths. Over 2.1 million
Americans live with a prescription opioid addiction while
467,000 Americans are addicted to heroin. These are devastating
numbers, and they have been trending upwards for far too long.
These numbers only paint a partial picture of the heavy
toll of the epidemic in our society. Throughout this country,
countless families and communities have been shattered by
opioid abuse, misuse and addiction. It is time that we really
truly pursue best practices supported by scientific research
that will reverse this problem.
Recent advances in science have shown us that addiction is
a disease of the brain. This demands that we approach the
problem not only as a public safety issue but also as a public
health issue. Yes, we must stop drug smugglers and crack down
on pill mills, but we also must work with prescribers to
educate them and prevent the over-prescription of opioids for
pain management. And most importantly, we must improve our
ability to identify and treat people with substance abuse
disorders.
In 2013, for example, only 1 in 10 Americans with a
substance abuse disorder received any form of treatment. That
is just unacceptable, and we should be asking why so few
Americans are accessing the treatment they need.
Research indicates that medication-assisted treatment, or
MAT, combined with counseling is the most effective way to
treat opioid addiction. Studies further demonstrate that MAT
reduces the risk of drug overdoses, infectious disease
transmission, and engagement in criminal activities.
Despite this track record, in 2013, MATs were available in
only 9 percent of substance abuse treatment facilities
nationwide. Even more troubling are reports that some treatment
facilities that adopt an abstinence-based approach to drug
treatment do not allow patients to take MATs while enrolled in
their programs. According to experts, a high percentage of
opioid addicts in abstinence-based treatment return to opioid
abuse within 1 year, and as you said, Mr. Chairman, even within
a few weeks. Given the limited success of these programs in
promoting long-term recovery in opioid addicts, we must ask
some hard questions regarding how we should be spending our
limited resources for treatment.
Finally, we know that patients with substance abuse
disorders continue to face significant barriers to treatment.
For example, right now there is a nationwide shortage of
qualified substance abuse providers, particularly people who
can prescribe MATs. Recent press reports also suggest that
patients face long waiting lists for admission into treatment
facilities, and according to the American Society of Addiction
Medicine, both State Medicaid programs and private insurers
have policies in place that are limiting patients' access to
MATs. We need to better understand these barriers and what we
can do at the federal level to address them.
There are some reasons for optimism, however. First, the
Affordable Care Act has expanded access to substance abuse
treatment for millions of Americans. Insurance companies are
now required to provide coverage of treatment for substance
abuse disorders just as they would for any chronic disease.
These policies represent the largest extension of treatment
access in a generation, and hopefully they will guide millions
into successful recovery.
Second, we do have some sense of what works. Some of our
witnesses today who have firsthand knowledge on what strategies
are effective to treat and prevent substance abuse will talk
about that. They know what has worked in their communities, and
we need to have them help us inform the national discussion.
I do want to thank our witnesses today, Mr. Chairman. We
have asked all of you to attend this hearing because of the
important work that you are doing to raise drug awareness,
break down the stigmas long associated with substance abuse
disorders, and put people on the path to recovery.
Finally, Mr. Chairman, your continued oversight on this
issue gives me reason to be optimistic that this committee can
play a role in turning the tide. You have indicated your
intention to conduct a series of hearings on this topic, and I
am certainly glad to be your partner in this inquiry.
To that end, I suggest that our next hearing focus on state
responses to the epidemic. There is significant variation from
state to state on treatment quality, access and coverage. Some
states are making progress but some are not, and we should hear
the best practices. We also need to hear from federal agencies
on these same topics.
This committee has an opportunity to make a meaningful
difference in addressing the problem, and I am welcoming all of
our joint efforts.
And with that, Mr. Chairman, I just want to let the
witnesses know, this committee has a bill on the floor right
now, so I have to run down and make a statement on the floor. I
am leaving us in the capable hands of Mr. Kennedy, and I will
be back after my statement. Thank you.
Mr. Murphy. I thank the gentlelady, and thank you for your
comments--very pointed.
I now recognize the chairman of the full committee, Mr.
Upton, for 5 minutes.
OPENING STATEMENT OF HON. FRED UPTON, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF MICHIGAN
Mr. Upton. Well, thank you, Mr. Chairman.
Today we continue our important review of the growing
epidemic of prescription drug and heroin abuse. The state and
local perspective of this growing threat is essential as we
evaluate what steps we can take at the federal level to help
address the crisis.
Sadly, communities all across the country have been
affected by prescription drug and heroin abuse, including my
district in southwest Michigan. Devastatingly, heroin overdoses
sadly are on the rise due to a combination of high demand and
purity that can make the drug even more lethal. There were 13
suspected overdoses in Kalamazoo in the first quarter of 2013,
compared to nine in the quarter before that in the earlier
year. This unwelcome trend is unfortunately all too familiar as
opiate-related overdoses have recently become the number one
cause of death in Michigan and nationwide, surpassing motor
vehicle crashes, suicide, firearms, and homicide.
I know personally a number of families that have been
shattered by that overdose. The reality of heroin overdoses has
hit hard in Kalamazoo County the last few years. In 2008, we
lost a beautiful little girl named Amy Bousfield, 18 years old.
In 2012, Marissa King died at 21. She began using heroin in
2009, despite having lost two friends to the drug. Marissa had
an underlying mental illness. She was diagnosed with bipolar
disorder, had struggled with depression, and had abused
prescription drugs before turning to heroin after graduating
from a local high school. These are just a few of the
heartbreaking stories that we see all across the country. We
are losing about 20,000 people a year from abuse of
prescription pain killers or heroin.
As we continue to mourn the loss of all these lives,
testimony from you all today will provide us an effective
approach making a real difference in fighting this awful abuse.
This is a great opportunity for this committee, on a bipartisan
basis, to help improve the federal government's response to
this epidemic. I am especially pleased to welcome one of
today's witnesses, my good friend Vic Fitz, the Cass County
Prosecutor and the President of the Prosecuting Attorneys
Association of Michigan. He has 31 years of experience in
prosecuting drug cases, and will certainly share his insights
today as he has done with me over the past number of years and
with other fellow prosecutors in Michigan on this issue. I
would note that the heroin dealer who sold the heroin that
killed Amy Bousfield was caught, convicted, and sentenced to 10
\1/2\ to 40 years in prison. We appreciate the work of Vic and
his fellow prosecutors who have held dealers accountable to the
law, and helped addicts straighten out their lives. I thank him
and all of you for your service, and for participating at
today's hearing, and I yield the balance of my time to Mr.
McKinley.
[The prepared statement of Mr. Upton follows:]
Prepared statement of Hon. Fred Upton
Today we continue our important review of the growing
epidemic of prescription drug and heroin abuse. The state and
local perspective of this growing threat is essential as we
evaluate what steps we can take at the federal level to help
address this crisis.
Sadly, communities all across the country have been
affected by prescription drug and heroin abuse, including
southwestern Michigan. Devastatingly, heroin overdoses are on
the rise due to a combination of high demand and purity that
can make this drug more lethal. There were 13 suspected
overdoses in Kalamazoo in the first quarter of 2013, compared
to 9 in the first quarter of 2012.
This unwelcome trend is unfortunately all too familiar as
opiate-related overdoses have recently become the No.1 cause of
death in Michigan and nationwide, surpassing motor vehicle
crashes, suicide, firearms, and homicide.
The reality of heroin overdoses has hit hard in Kalamazoo
County the last few years. In 2008, we lost Amy Bousfield, 18
years old and a graduate of Portage Central High School. In
2012, Marissa King died at 21 years old. She began using heroin
in 2009, despite having lost two friends to the drug, including
Amy Bousfield. Like 40 percent of those who abuse drugs,
Marissa had an underlying mental illness. She was diagnosed
with bipolar disorder, had struggled with depression, and had
abused prescription drugs before turning to heroin after
graduating from Comstock High School.
There are many heart-breaking stories like this across the
country. We are losing about 20,000 people a year from abuse of
prescription pain killers or heroin. As we continue to mourn
the loss of all these lives, testimony from today's witnesses
provides us hope that there are effective approaches making a
real difference in fighting opioid abuse. This is a great
opportunity for this committee, working on a bipartisan basis,
to help improve the federal government's response to this
epidemic.
I am especially pleased to welcome one of today's
witnesses, my friend Vic Fitz, the Cass County Prosecutor and
the President of the Prosecuting Attorneys Association of
Michigan. Vic has 31 years of experience in prosecuting drug
cases, and will share his insights as well as those of his
fellow prosecutors in Michigan on this issue. I would note that
the heroin dealer who sold the heroin that killed Amy Bousfield
was caught, convicted, and sentenced to 10 and a half to 40
years in prison. We appreciate the work of Vic and his fellow
prosecutors who have held dealers accountable to the law, and
helped addicts straighten out their lives. I thank him for his
service, and for participating at today's hearing.
Mr. McKinley. Thank you, Mr. Chairman, and thank you, Mr.
Murphy, for holding this hearing today focusing on this growing
epidemic. Thank you to the witnesses for coming here to
testify.
Prescription drug and heroin abuse has steadily increased.
You have heard it throughout the comments that have been made
here and throughout our country, and I have seen it firsthand
in my home State of West Virginia. Currently, West Virginia is
suffering from the highest rate of drug overdose mortality
rates in the entire country.
Since coming to Congress in 2010, our office has been
working on solutions. We have had roundtable meetings
throughout the district with law enforcement, healthcare
professionals, educators, and community leaders about how to
address this problem. What we have heard is at least three
solutions. One is, we need to be focused better on education;
secondly, on proactive prevention; and thirdly, resources for
our law enforcement to take these drug traffickers off our
streets. Therefore, by expanding the High Incident Drug Traffic
Area--HIDTA--in West Virginia, it has provided an incredibly
effective tool for catching drug offenders and taking them off
the streets. This is just one option. I hope to learn more from
the rest of this panel today.
Thank you, and I yield back my time.
Mr. Murphy. Thank you. The gentleman yield back. I now
recognize Mr. Kennedy of Massachusetts for 5 minutes.
OPENING STATEMENT OF HON. JOSEPH P. KENNEDY, III, A
REPRESENTATIVE IN CONGRESS FROM THE COMMONWEALTH OF
MASSACHUSETTS
Mr. Kennedy. Thank you, Mr. Chairman. Thank you very much
to all the witnesses that are here today who have dedicated so
much of their time, efforts, energy, and lives to confronting
this crisis, either through treatment, community health or
through law enforcement. We are grateful for your commitment
and all you do to try to address this problem head-on, and I
want to thank the chairman of the committee and of the
subcommittee as well for calling an important hearing.
There are few people in this country that have been spared
the heartbreaking impact of watching a loved one, a neighbor, a
friend, a colleague fall victim to opiate addiction. It is an
epidemic striking red states and blue states, small towns and
big cities, neighborhoods rich and poor. The breadth and depth
of this epidemic is truly staggering, and there is no silver
bullet. But perhaps there is a silver lining, which you have
heard already this morning. It translates into strong
bipartisan consensus here in Washington that we have to do
something about it.
Back home in the 4th District of Massachusetts, there is
not an event that I go to where this topic does not come up.
Communities like Fall River in Taunton have been particularly
hard-hit. Local leaders are working tirelessly to respond.
Across the Commonwealth, we confront a growing epidemic. In
2013, there were 978 opioid-related deaths in Massachusetts,
according to the Department of Public Health, which has yet to
release 2014 figures. In fiscal year 2014, there were more than
104,000 admissions to State-contracted substance abuse
treatment programs in Massachusetts, more than 53 percent of
which were for heroin addiction.
Despite these numbers, I repeatedly hear from providers in
my district that there is a profound lack of resources for the
prevention and treatment of substance abuse, especially when it
comes to opioid addiction. Insufficient wraparound services,
low reimbursement rates, and bureaucratic barriers to treatment
harm patients and undermine our efforts to reverse addiction
trends.
According to CPAC, the New England Comparative
Effectiveness Public Advisory Council, 133,000 people in New
England abuse or are addicted to opiates. Of those, 70 percent
meet the criteria for treatment but cannot access it. We know
that this is a problem with no silver bullet solution. We are
working to chip away at it, and I am proud to have joined
Representative Whitfield this morning in reintroducing
legislation to reauthorize the NASPER program, the National All
Schedules Prescription Electronic Reporting program. The
program is designed to provide grants to states for the
establishment, implementation, and improvement of prescription
drug monitoring programs. We know that timely access to patient
records and high standards of interoperability are successful
with PDMPs, and this legislation will give providers the tools
that they need to identify and treat at-risk behavior.
To those of you who are here today to testify, you are on
the frontlines of this epidemic. You are fighting every single
day for our communities, our neighborhoods and our backyards.
This gives you unparalleled insight into what works and to what
doesn't. We are here today to learn from you, to take the
lessons that you have learned from your cities and towns, and
try to transport them across the entire country.
Let me just say I first became aware of the scope of this
addiction and the scope of this problem as a prosecutor in
local communities in Massachusetts, finding young men and women
that were breaking into 15 cars in a night, five, six homes
over the course of the weekend, undercover agents that were
putting themselves at great risk to try to keep our communities
safe. So for those of you in law enforcement that are here, I
look forward to hearing your ideas. From those folks back home
that I have talked to, they have profound recognition that we
will not arrest our way out of this problem, but very much look
forward to hearing your solutions as to what we can do going
forward, and I yield back my time.
Mr. Murphy. I thank the gentleman for yielding your time.
You are all done on your side? All right. Thank you.
What we are going to do is, I am going to swear in the
witnesses and then I am going to ask members who invited
witnesses to introduce each one of you briefly, and hopefully
we will get your testimony done before votes because we do want
to hear from you and ask questions.
So you are all aware that the committee is holding an
investigative hearing, and when doing so has the practice of
taking testimony under oath. Do any of you have any objections
to giving testimony under oath? Seeing no objections, the chair
then advises you that under the rules of the House and the
rules of the committee, you are entitled to be advised by
counsel. Do any of you desire to be advised by counsel during
your testimony today? No one indicates they want counsel, so in
that case, if you would all please rise and raise your right
hand, I will swear you in.
[Witnesses sworn.]
Mr. Murphy. You may sit down. All the witnesses have
indicated in the affirmative. You are under oath and subject to
the penalties set forth in Title XVIII, Section 1001 of the
United States Code.
We will call upon you each to give a 5-minute summary of
your written testimony. We will start off with Mr. Fred Wells
Brason, and Mr. Hudson of North Carolina will introduce the
witness.
Mr. Hudson. Thank you, Mr. Chairman.
I am pleased today to introduce Fred Wells Brason, a former
hospice chaplain, now President and CEO of Project Lazarus from
my home State of North Carolina. Mr. Brason has had tremendous
success in saving lives from opioid overdoses, and I look
forward to hearing his testimony and learning from his great
work.
Mr. Murphy. Mr. Brason, you are recognized--is it Brason or
Branson?
Mr. Brason. Brason.
Mr. Murphy. Mr. Brason, you are recognized for 5 minutes.
Turn the mike on, pull it close to you, watch the red light.
That will tell you when you are done. Thank you.
STATEMENT OF FRED WELLS BRASON, II, EXECUTIVE DIRECTOR, PROJECT
LAZARUS, MORAVIAN FALLS, NORTH CAROLINA; DR. SARAH T. MELTON,
PHARMD, BCPP, BCACP, CGP, FASCP, ASSOCIATE DIRECTOR OF PHARMACY
PRACTICE, GATTON COLLEGE OF PHARMACY AT EAST TENNESSEE STATE
UNIVERSITY, JOHNSON CITY, TENNESSEE, AND CHAIR OF THE BOARD OF
DIRECTORS OF ONECARE OF SOUTHWEST VIRGINIA, BRISTOL, VIRGINIA;
STEFAN R. MAXWELL, M.D., ASSOCIATE PROFESSOR, PEDIATRICS, WVU
SCHOOL OF MEDICINE, MEDNAX MEDICAL GROUP, MEDICAL DIRECTOR,
NICU, WOMEN AND CHILDREN'S HOSPITAL, CHARLESTON, WEST VIRGINIA;
RACHELLE GARDNER, CHIEF OPERATING OFFICER, HOPE ACADEMY,
INDIANAPOLIS, INDIANA; VICTOR FITZ, CASS COUNTY, MICHIGAN,
PROSECUTOR, AND PRESIDENT OF THE PROSECUTING ATTORNEYS
ASSOCIATION OF MICHIGAN (PAAM), CASSOPOLIS, MICHIGAN; CORPORAL
MICHAEL GRIFFIN, NARCOTICS UNIT SUPERVISOR--K9 HANDLER, SPECIAL
INVESTIGATIONS DIVISION, TULSA POLICE DEPARTMENT, TULSA,
OKLAHOMA; AND DR. CALEB BANTA-GREEN, SENIOR RESEARCH SCIENTIST,
ALCOHOL AND DRUG ABUSE INSTITUTE, UNIVERSITY OF WASHINGTON,
SEATTLE, WASHINGTON
STATEMENT OF FRED WELLS BRASON, II
Mr. Brason. Thank you very much. Chairman Murphy, thank you
for convening this and giving us the opportunity to share what
is happening on the streets of our communities and our response
to the issues that we encounter, and I am talking back to 2004
as a hospice chaplain realizing the medication issues that were
happening in our community homes where families were stealing,
sharing, and selling the medication of and with the patients.
Having addressed it that way and not having any solutions,
we in Wilkes County, North Carolina addressed it from a public
health perspective: this is our house, our community, and we
need to fix it. And by doing that, we convened all the
community sectors that we could, and working with each single
one to derive a solution-based process from our schools to our
law enforcement to our medical community to our prescribers,
and in doing that, we created a public health model to sort of
bring awareness to the issue but then also making sure that
there is a balanced approached so that we are talking about
prevention, intervention, and treatment across the spectrum. We
do want to prevent the overdoses from occurring but we also
want to ensure that patients can have access to care, receive
the medication and the treatment that they are entitled to but
receive it safely and appropriately, but then those individuals
who do have and have developed a substance use disorder,
disease of addiction and so forth, that they have a safety net
so that they are not just pushed into the heroin or they are
not pushed someplace else.
A community has to address all of those facets, and we
began by addressing first community awareness and community
education so that individuals receiving a prescription can take
it correctly, store it securely, dispose of it properly, and
never share. Unfortunately, those are common practices that go
on in our community with the right prescription for the right
person but when it is in the home, the family is feeling like,
well, it is OK because the doctor wrote it. Those are some of
the public health reversals that we need to do. Then we work
with our prescribing community to, you know, look at how to
best manage chronic pain, how to manage acute pain, how to
appropriately prescribe but then also how to assess patients,
how to determine they are at risk, you know, possibilities, but
then also looking within the community, and if there is a risk
of something already has developed, who can I have the warm
handoff to for the treatment that is necessary to them, whether
it is an abstinence program, whether it is a medication-
assisted treatment, whether it is a methadone or a
buprenorphine or naltrexone. There isn't one treatment that
works for everybody but there is treatment that works for
everybody, so we have to make sure our communities have
accessibility for all of that, and that is what we look for in
our community and we are able to do that by education.
When I first mentioned methadone, I thought I was leaving
North Carolina permanently. It was not a pleasant time. But
after education and understanding of what treatment is and how
the brain is affected when somebody has been using for a while,
there has to be a stabilization. There has to be a bridge, and
we have to be able to provide that to those who are in trouble.
But then as we address the prescribing community, then we
also had to talk to our law enforcement, work with them on
diversion techniques, the take-back programs, the permanent
drop-offs for old meds in the home because in 2012, we did
dispense 259 million prescriptions, which means we have
accidental ingestion going on, especially among toddlers. So we
have patients misusing, unfortunately overdosing. We have
toddlers' accidental ingestion, unfortunately overdosing. We
have families and friends sharing with unfortunate overdosing.
We have recreational users going out for a good time and
somebody having a pill for them dying from an overdose, and
then we have those with substance use disorder dying from an
overdose. Looking at all of those categories within our
population groups, we have to address all population groups,
all ages from a public health perspective to reverse the
behaviors, the misconceptions, and the problems that arise from
that but ensuring that those that need it can receive it, those
that need treatment can receive it and have it.
So as we did that, then we looked at, you know, what
treatments could we bring into the community, and then we
introduced naloxone. The North Carolina Medical Board was the
first medical board in the country to come forth with a
position statement that best practice is supporting and having
an available naloxone, especially co-prescribing that with a
medication to those individuals who are at risk. A person at
risk could just be released from jail or person. A person at
risk could be receiving methadone for treatment or for pain. A
person at risk could be receiving opioid medication for their
pain or they have a previous history for substance use. So,
there is a broad base for the naloxone. It just needs to be
made available, and thankfully, out of the State of Virginia,
they are putting forth a law that sort of mandates co-
prescribing of naloxone to a person receiving extended release
or long-acting opioid medication. It is a safety factor. It is
not a treatment but it is a rescue medication, and many of our
communities now, especially Massachusetts, North Carolina and
others, law enforcement are saving lives, and that is what is
important to them. So it is a safety factor to do that.
But without a comprehensive approach, there is not any one
single bullet, there is not any one single thing. It has to be
everything and it has to be all of us in order to drive the
change from a public health perspective and have best practice
from the individual to the prescribers, to the emergency
departments, and everybody in between to accomplish that.
Thank you for your time.
[The prepared statement of Mr. Brason follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Murphy. Thank you very much.
Now we are going to recognize Dr. Sarah Melton, and Mr.
Griffith of Virginia is going to introduce you.
Mr. Griffith. Thank you very much, Mr. Chairman.
I am glad to introduce Dr. Sarah Melton. Dr. Melton chairs
OneCare of Southwest Virginia, a consortium of substance abuse
coalitions attempting to turn the tide against substance abuse.
She is an Associate Professor of Pharmacy at ETSU and most
recently was appointed by Governor Terry McAuliffe to the
Virginia Task Force on Prescription Drug and Heroin Abuse, an
idea first proposed to the Governor by myself and others in the
Virginia Congressional Delegation.
Dr. Melton has a long history of working to address the
substance abuse problems in southwest Virginia. She was
instrumental in bringing Project Lazarus to Virginia, and she
is also working on the naloxone issues in southwest Virginia
and in Virginia. I want to thank you, Dr. Melton, for being
here today and sharing your experience with our committee.
Mr. Murphy. Dr. Melton, you are recognized for 5 minutes.
STATEMENT OF SARAH T. MELTON
Ms. Melton. Thank you, Mr. Chairman, and thank you,
Congressman Griffith and the other members of the subcommittee.
During my testimony, I am going to address key areas
related to state and local initiatives that are making an
impact, and I will also address key areas where I feel the
federal government can assist in these areas.
The first key area I will address is education of
prescribers. As you are all aware, students and residents in
healthcare professions have limited exposure to curricula in
identifying and treating substance use disorders and
appropriate prescribing and dispensing of controlled substances
for chronic pain, but in Virginia, we are working together to
bring leaders from all healthcare schools together to assure
that our prescribers and dispensers of controlled substances
have received an adequate education on addiction and the
treatment of chronic pain.
Overall, more funding is needed form the federal level to
provide expanded graduate medical education opportunities for
training in the identification, referral, and treatment of
substance use disorders. As changes in federal funding
allocated for graduate medical education are currently being
discussed, it is an opportune time to assess how funding can
best address training in addiction medicine.
Tennessee has a mandated annual continuing education
requirement for prescribers. Virginia, however, does not have
that. OneCare of Southwest Virginia has joined with the Medical
Society of Virginia and the Virginia Department of Health to
provide no-cost continuing medical education to all healthcare
prescribers as well as dispensers. We have been able to educate
over 2,000 prescribers and dispensers in the past 3 years. We
are currently evaluating how that continuing education has
changed prescribing habits, attitudes, and registration to the
prescription drug monitoring program as well as other outcomes.
I wanted you to know that in January, a letter was sent
directly from Secretary of Health and Human Services, Dr. Bill
Hazel, to all prescribers in Virginia. The letter specifically
addressed new legislation that requires prescribers to be
monitored, to be registered in the prescription drug monitoring
program, but it also talked about how to use the PMP programs
in clinical practice. I am happy to report as a result of that
letter, the prescription drug monitoring program registrations
dramatically increased, and we are seeing a steady increase in
inquiries to the PMP in the clinical setting. We are going to
be sending a letter to all pharmacists in the Commonwealth in
the next month.
With regard to access to naloxone, both Virginia and
Tennessee have recently passed legislation that will provide
wide access to this lifesaving medication, and OneCare has
worked extensively with the Virginia Department of Behavioral
Health and Developmental Services to train people across the
Commonwealth through Project Revive. Last summer, Senator Tim
Kaine attended one of those trainings in Lebanon, Virginia, and
as a result of his training, he has introduced legislation
through the Opioid Overdose Reduction Act to offer Good
Samaritan protection for first responders. It is my hope that
Congress will pass this legislation so that we have a
consistent Good Samaritan protection across the Nation.
One barrier we are finding with naloxone, though, is the
cost. It is not mandated by insurance companies to cover this
medication, and it really should be.
With regard to treatment, medication-assisted treatments
with methadone, buprenorphine, and naltrexone have become an
essential component of a comprehensive treatment plan for
opioid use disorders. The issue that we have now is that we
need a modernization of federal law to further expand access to
these lifesaving medications but we need specific best practice
requirements and recommendations for prescribers and insurers
such as Medicaid and Medicare to make sure that certain
patients are receiving comprehensive care by competently
trained healthcare providers. Also critical is reimbursement
for parts of these programs such as urine drug screens and the
necessary psychotherapy that accompanies the medication
treatment.
With regard to monitoring with the prescription drug
monitoring program, both Virginia and Tennessee are members of
the National Association of Boards of Pharmacy Interconnect
program, and I am very happy to find that the bill that will
find NASPER is being proposed because the funding for that
allocation will help all States be able to participate in a
national prescription drug monitoring program. There is one
concern I have, though. You may or may not know, a concern that
we encounter daily in clinical practice is that methadone
clinics are not required to report methadone dispensing to the
prescription drug monitoring programs. This is a very serious
situation because if these patients do not disclose this to
their primary care providers and they don't know it when they
access the prescription drug monitoring program, we often see
other opioids being prescribed, benzodiazepines that can lead
to death. So that is an issue of concern. And in contrast,
buprenorphine, of course, is reported to the State prescription
drug monitoring programs that allow us more monitoring for
safety and appropriate use.
Thank you for the opportunity to testify and for your
ongoing commitment to this epidemic across the United States.
[The prepared statement of Ms. Melton follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Murphy. Thank you.
Now I am going to recognize the vice chair of the
subcommittee, Mr. McKinley, to introduce Dr. Maxwell.
Mr. McKinley. Thank you, Mr. Chairman.
Dr. Stefan Maxwell is a neonatalist in Charleston, West
Virginia, caring for the sickest of the newborns for the past
30 years. He is Chairman of the West Virginia Perinatal
Partnership, which focuses on reducing the number of babies
born who are exposed to drugs. A study in this topic in 2009
revealed that 20 percent, one in five, babies born in West
Virginia were exposed to a substance during the pregnancy.
Dr. Maxwell's work in the Perinatal Partnership in West
Virginia has led to great strides in finding ways to identify
women in need of drug treatment counseling and reduce the
number of babies born exposed to drugs. His leadership as
Chairman of the Perinatal Partnership and the Committee on
Substance Abuse in Pregnancy, a member of the West Virginia
Governor's Advisory Council on Substance Abuse, and caring for
sick babies at Charleston Area Medical Center has made him a
leading expert on this topic.
Thank you, Dr. Maxwell, for attending here today and
providing us your experiences.
Mr. Murphy. Doctor, you are recognized for 5 minutes.
STATEMENT OF STEFAN R. MAXWELL
Dr. Maxwell. Thank you Congressman McKinley and thank you,
Mr. Chairman for the opportunity. It is pretty humbling to be
asked to speak with such an august group, but hopefully this
testimony will help us in your quest to quell this rising tide
that is a scourge in our Nation.
I have had the opportunity to take care of these babies
that are suffering from neonatal abstinence syndrome, and so at
the time back in 2006 when the West Virginia Perinatal
Partnership was established, their mission was to look at areas
that we could improve the health of mothers and babies in West
Virginia, and at the time when all of the providers got
together in a room, we decided that substance abuse in
pregnancy or substance usage in pregnancy was an issue that we
had to address, mainly because at the time, these babies that
had neonatal abstinence syndrome were taking up most of the
beds in the ICU, and level III institutions could not accept
sick, small, premature babies from outlying institutions. Some
of them had to be transported out of the State.
So at the time, we really were not understanding the whole
impact of what was happening in the State. So I missed a
meeting and became chairman of the substance abuse committee, I
have to say, and I was given that responsibility, and over the
ensuing 3 years or so, we tried to figure out what was the
prevalence of this problem in our State, and so we embarked
upon the umbilical cord tissue study, which looked at eight
hospitals through the State, scattered throughout the State. We
collected as many umbilical cord tissue samples as we could as
sort of a pilot over a month-long period. We ended up
collecting almost 800 samples, and then we realized that one in
five of those samples was positive for a substance, many of
them being polydrug abusers, which included opiates, marijuana,
and so forth.
So this was obviously a daunting problem, and so at the
Perinatal Partnership we decided to try to be proactive rather
than reactive, and by that, I mean we wanted to see if we could
reduce the numbers of babies with neonatal abstinence or at
least reduce the severity of the neonatal abstinence syndrome
at the end of the pregnancy. So we embarked upon a project that
we called the Drug-Free Mothers and Babies Project whereby we
sent out requests for proposals, got four or five in, and now
have established four or five programs that are in the process.
The aspects of this project are, one, we screen all women at
the first antenatal visit, whether we do it using biological
specimens like urine or we do it with screening tools such as
what we call SBIRT screening, brief intervention, referral, and
treatment. And then once we have identified a woman, a pregnant
woman, who is using an opiate specifically, we then refer them
to an addiction counselor and behavioral medicine, and try to
follow them throughout that pregnancy with a goal to reducing
or first of all converting the substance they are using to
another drug that we can probably wean throughout the pregnancy
with a goal to reducing the amount of drug that the baby is
exposed to during the pregnancy and ultimately get them either
off the drug or on a very small dose so that the severity of
neonatal abstinence would be that much reduced.
Well, one of those programs has been operating now for
about 2 years, and we have had great success with one of those
programs, reducing their incidence of 19 percent of positive
umbilical cord tissue samples at birth to 8 percent, which
means that the cost associated with neonatal abstinence has
been significantly reduced. We have also been following these
ladies who have been in the program for up to a year. We don't
have 2 years' worth of follow-up yet, but the goal is to follow
them at home for the first 2 years after delivery and reinforce
that behavioral modification that went on throughout the
pregnancy.
The ultimate goal if this is a successful program is to
develop what we call a pay-for-success program, whereby we can
now try to save the government money in the long run by having
an investor fund these programs, have an independent entity
such as the Partnership administer the program with an
independent audit, and at the end hopefully show that we have
reduced the cost and ultimately improved the lives of these
people that are ravaged by this terrible disease.
Thank you for the opportunity, Mr. Chairman.
[The prepared statement of Dr. Maxwell follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
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:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
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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