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




 
    COMBATING THE OPIOID ABUSE EPIDEMIC: PROFESSIONAL AND ACADEMIC 
                              PERSPECTIVES

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

                                HEARING

                               BEFORE THE

              SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

                                 OF THE

                    COMMITTEE ON ENERGY AND COMMERCE
                        HOUSE OF REPRESENTATIVES

                    ONE HUNDRED FOURTEENTH CONGRESS

                             FIRST SESSION

                               __________

                             APRIL 23, 2015

                               __________

                           Serial No. 114-34
                           
                           
                           
                           
                           
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]                       



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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)

                                  (ii)
                                  
                                  
                                  
                                  
                             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. Marsha Blackburn, a Representative in Congress from the 
  State of Tennessee, opening statement..........................     7
Hon. Janice D. Schakowsky, a Representative in Congress from the 
  State of Illinois, opening statement...........................     8
Hon. Paul Tonko, a Representative in Congress from the State of 
  New York, opening statement....................................     9

                               Witnesses

Robert L. DuPont, M.D., President, Institute for Behavior and 
  Health, Inc....................................................    11
    Prepared statement...........................................    13
    Answers to submitted questions...............................   105
Marvin D. Seppala, M.D., Chief Medical Officer, Hazelden Betty 
  Ford Foundation................................................    22
    Prepared statement...........................................    25
    Answers to submitted questions...............................   107
Laurence M. Westreich, M.D., President, American Academy of 
  Addiction Psychiatry...........................................    38
    Prepared statement...........................................    40
Anna Lembke, M.D., Assistant Professor, Psychiatry and Behavioral 
  Sciences, Stanford University School of Medicine...............    45
    Prepared statement...........................................    48
    Answers to submitted questions...............................   111
Adam Bisaga, M.D., Research Scientist, New York State Psychiatric 
  Institute......................................................    54
    Prepared statement...........................................    56
Patrice A. Harris, M.D., Secretary, Board of Trustees, American 
  Medical Association............................................    68
    Prepared statement...........................................    70
    Answers to submitted questions...............................   115

                           Submitted Material

Subcommittee memorandum..........................................    98


    COMBATING THE OPIOID ABUSE EPIDEMIC: PROFESSIONAL AND ACADEMIC 
                              PERSPECTIVES

                              ----------                              


                        THURSDAY, APRIL 23, 2015

                  House of Representatives,
      Subcommittee on Oversight and Investigations,
                          Committee on Energy and Commerce,
                                                    Washington, DC.
    The subcommittee met, pursuant to call, at 10:17 a.m., in 
room 2322 of the Rayburn House Office Building, Hon. Tim Murphy 
(chairman of the subcommittee) presiding.
    Members present: Representatives Murphy, McKinley, Burgess, 
Blackburn, Bucshon, Brooks, Mullin, Hudson, Collins, Cramer, 
DeGette, Schakowsky, Tonko, Clarke, Kennedy, and Green.
    Staff present: Leighton Brown, Press Assistant; Noelle 
Clemente, Press Secretary; Brittany Havens, Legislative Clerk; 
Graham Pittman, Staff Assistant; Chris Santini, Policy 
Coordinator, Oversight and Investigations; Alan Slobodin, 
Deputy Chief Counsel, Oversight; Sam Spector, Counsel, 
Oversight; Jean Woodrow, Director, Information Technology; Jeff 
Carroll, Democratic Staff Director; Ashley Jones, Democratic 
Director, Outreach and Member Services; Christopher Knauer, 
Democratic Oversight Staff Director; Una Lee, Democratic Chief 
Oversight Counsel; and Elizabeth Letter, Democratic 
Professional Staff Member.

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

    Mr. Murphy. All right, good morning. We are here at the 
Oversight and Investigations Subcommittee hearing on Combating 
the Opioid Abuse Epidemic: Professional and Academic 
Perspectives. Welcome.
    Less than 1 month ago, on March 26, we held the first in a 
series of hearings to examine the growing problems of 
prescription drugs and heroin abuse. During that brief span of 
time, according to the best estimates from the Department of 
Health and Human Services, at least 3,374 Americans will have 
died from drug overdoses, with opioids being the most common 
cause. That is 3,374 overdose deaths in less than 1 month. 
Indeed, during the time we spend in this hearing, another 10 
lives will be lost.
    The headlines out of Pittsburgh last week sent shockwaves 
throughout my district with 10 heroin overdoses in a single 24-
hour period. Of the two who died, they were found with stamped 
bags marked either ``Chocolate'' or ``Chicken/Waffle.'' And 
this is what we are up against. This is what is killing our 
sons and daughters, brothers and sisters, mothers and fathers.
    Let me state clearly so as to leave no room for doubt: Our 
current strategy just isn't working, and I am not going to stop 
until we start moving in the direction of success, defined not 
just as getting individuals off of street drugs and onto a 
Government-approved opioid, but getting them to the point of 
drug-free living.
    About 3 weeks ago, on the very same day this committee held 
our first hearing on this issue, the Department of Health and 
Human Services released its long-awaited three-part plan to 
reverse this epidemic. Elements of the plan made sense; 
however, I am puzzled and amazed to read one particular 
priority included in their press release, and I quote, 
``Exploring bipartisan policy changes to increase use of 
buprenorphine and developing the training to assist 
prescribing.''
    We are in desperate need of innovations to reverse the 
current trend and not merely maintain it. Why would we focus 
only a single opioid replacement program rather than the full 
range of FDA-approved treatments for opioid addiction? Why the 
fixation on one pharmaceutical product? According to testimony 
presented to this committee last year by the Director of 
SAMHSA's Center for Substance Abuse Treatment, nearly 1 million 
people were prescribed buprenorphine in 2011. We know that 
number is much higher today, probably closer to 1.5 million 
people or more. Think about that. Success by Federal Government 
standards for addiction disorders is 1.5 million people 
prescribed synthetic opioids. Yet, consider the sad fact that 
States have not seen their investment in prescription clinics 
reverse this opioid epidemic. States like Maryland, Vermont, 
Massachusetts and others that have made massive investments in 
buprenorphine maintenance have not seen reductions in overdose 
deaths. On the contrary, things have gotten much much worse.
    According to the DEA, buprenorphine is the third most 
confiscated drug in law enforcement activities in our country 
today. More than morphine, more than methadone, more than 
codeine. Patients are routinely getting buprenorphine 
prescribed as ``heroin helper'', meaning they get a month's 
supply of buprenorphine to use whenever they can't get heroin. 
It tides them over, enabling them to remain in their active 
addiction. This should more accurately be called addiction 
maintenance, not just the euphemistically called, opioid 
maintenance.
    Some addicted to methamphetamines go to local bupe mills 
and get a 30-day supply that they promptly sell to buy their 
drug of choice. In the field of addiction treatment, the 
enabler is part of the problem. Helping intentionally or 
unintentionally to keep a family member as an alcohol or drug 
addict is enabling. Here, the U.S. Government is the biggest 
enabler of them all.
    Some clinics operate cash-only businesses for writing 30-
day supplies of buprenorphine at the highest permissible doses; 
usually 32 milligrams, knowing full well patients will sell at 
least of half of the pills in order to pay for their treatment 
or other illicit drugs.
    At our last hearing, Professor Sarah Melton at East 
Tennessee University noted that that there are methadone 
clinics operating on a cash basis, handing out methadone 
without any other treatment, or buprenorphine pill mills. It is 
not acceptable that Federal taxpayer money be used to support 
programs that hand out these drugs for cash. Worse, Professor 
Melton testified that there was a dearth of good treatment 
programs. And what happens after the patient leaves the 
treatment program? What is being done to follow-up with 
patients to prevent relapses and put them on a path of real 
recovery? I fully recognize the importance of medication-
assisted treatment as a transition from street drugs and to 
prevent overdose from heroin, but relying on this as the one 
and only solution shouldn't be the strategy.
    As I recently heard Dr. McLellan, the former Deputy 
Director of ONDCP say, while there is an appropriate place for 
medication-assisted treatment, we should not turn a blind eye 
to the fact that there is also a tremendous amount of 
medication-assisted addiction. It is not acceptable for Federal 
taxpayer money to be used to support treatment programs that 
lack evidence of effectiveness, or that define success merely 
as an individual with an addiction disorder using heroin fewer 
times per week than before treatment.
    I am calling for a patient-centered initiative with a goal 
of matching patients with the most appropriate care, coupled 
with a focus on transition not just off street drugs, but 
eventual transition from opioids altogether. I hope to 
modernize our existing opioid addiction treatment system to 
ensure that the right patient gets the right treatment at the 
right time. It simply isn't true to present buprenorphine and 
methadone as opioid-free treatment. We do a tremendous 
disservice to those living with addiction disorders when we 
advance disingenuous double-talk and not state outright that 
buprenorphine and methadone are highly potent opioids.
    We are not going to end this opioid epidemic by increasing 
the use of opioids. We need an exit strategy that enables 
Americans to become opioid-free altogether. We can do better 
than addiction maintenance. We can and we must.
    I look forward to working with my colleagues and HHS as we 
explore new innovations for detoxification and treatment models 
to transition individuals off of all opioids and into evidence-
based counseling with non-addictive, non-narcotic behavioral 
and medication treatments. We don't do enough to help those 
addiction disorders. I believe in recovery. I believe in lives 
being restored so that every individual may live to their full 
God-given potential and do so drug free. I consider opioid 
maintenance as a bridge to cross over in addiction recovery, 
not a final destination. At this point, the Government simply 
stopped building the bridge. We have not yet fully helped move 
those with addiction disorders beyond opioid maintenance, and I 
seek to lay out a vision for recovery that includes complete 
withdrawal from opioids as an option. Once we lay out those 
goals, we can then move forward with research and clinical 
efforts, and boldly declare that we are no longer satisfied 
with the status quo of opioid maintenance only.
    To assist us today, the subcommittee will hear from some of 
the Nation's foremost professional and academic experts in the 
field of opioid addiction. Among these questions we hope these 
experts will address are, What can be done to incentivize 
individual compliance with prescribed treatment plans and 
reduce the risk of relapse? What should be the aim of treatment 
for opioid addiction: reduce the intake of illicit drugs by 
these individuals to more moderate levels, or should the aim be 
to place patients on a path to detoxification and ultimately a 
full recovery, ending all illicit uses and removing the need 
for lifelong opioid maintenance recovery? To what extent is the 
increased prescribing of methadone for pain contributing to 
more overdose deaths? Are Medicaid and Medicare payments for 
the treatment of pain incentivizing doctors to prescribe the 
opioids like candy for the treatment of pain?
    Today we have assembled some of the leading opioid 
addiction experts. We welcome you to get your thoughts on 
dealing with this epidemic. And I thank you for your expertise 
and look forward to hearing your testimony.
    [The prepared statement of Mr. Murphy follows:]

                 Prepared statement of Hon. Tim Murphy

    Less than one month ago, on March 26, we held the first in 
a series of hearings to ``Examine the Growing Problems of 
Prescription Drug and Heroin Abuse.'' During that brief span of 
time, according to the best estimates from the Department of 
Health and Human Services, at least 3,374 Americans will have 
died from drug overdoses, with opioids being the most common 
cause. That's 3,374 overdose deaths in less than one month. 
Indeed, during the time we spend in this hearing, another 10 
lives will be lost.
    The headlines out of Pittsburgh last week sent shock waves 
throughout my district: 10 heroin overdoses in a single 24-hour 
period. On the 2 who died were found stamped bags marked either 
``Chocolate'' or ``Chicken/Waffle.'' This is what we are up 
against. This is what is killing our sons and daughters; 
brothers and sisters, fathers and mothers.
    Let me state clearly so as to leave no room for doubt: Our 
current strategies are failing and I am not going to stop until 
we start moving in the direction of success defined not just as 
getting individuals off of street drugs and onto a Government-
approved opioid, but getting them to the point of drug free 
living.
    About three weeks ago, on the very same day this committee 
held our first hearing on this issue, the Department of Health 
and Human Services released its long-awaited three-part plan to 
reverse this epidemic. Elements of the plan make sense; 
however, I am puzzled and amazed to read one particular 
priority included in their press release (and I quote):
     Exploring bipartisan policy changes to increase 
use of buprenorphine and develop the training to assist 
prescribing.
    We are in desperate need of innovations to reverse the 
current trend and not merely maintain it. Why would we focus 
only a single opioid replacement program rather than the full 
range of FDA-approved treatments for opioid addiction? Why the 
fixation on one pharmaceutical product?
    According to testimony presented to this committee last 
year by the Director of SAMHSA's Center for Substance Abuse 
Treatment, nearly one million people were prescribed 
buprenorphine in 2011. We know that number is much higher 
today, probably closer to 1.5 million people or more.
    Think about that. Success by Federal Government standards 
for addiction disorders is 1.5 million people prescribed 
synthetic opioids. Yet, consider the sad fact that States have 
not seen their investment in prescription clinics reverse the 
opioid epidemic. States like Maryland, Vermont, Massachusetts 
and others that have made massive investments in buprenorphine 
maintenance have not seen reductions in overdose deaths. On the 
contrary, things have only gotten much much worse:
     According to the DEA, buprenorphine is the third 
most confiscated drug in law enforcement activities in our 
country today. More than morphine, more than methadone, more 
than codeine.
     ``Patients'' are routinely getting buprenorphine 
prescribed as ``heroin helper''--meaning they get a month's 
supply of buprenorphine to use whenever they can't get heroin. 
It tides them over,enabling them to remain in their active 
addiction. This should more accurately be called `` addiction 
maintenance'' not just the euphemistic, ``opioid maintenance.''
     Some addicted to methamphetamines go to local 
``bupe mills'' and get a 30-day supply that they promptly sell 
to buy their drug of choice.
     In the field of addiction treatment, the 
``enabler'' is part of the problem--helping intentionally or 
unintentionally to keep a family member as an alcoholic or drug 
addict. Here, the U.S. Government is the biggest enabler of 
them all.
     Some clinics operate cash-only businesses for 
writing 30-day supplies of buprenorphine at the highest 
permissible doses (usually 32 milligrams) knowing full well 
patients will sell at least of half of the pills in order to 
pay for their ``treatment'' or other illicit drugs.
    At our last hearing, Professor Sarah Melton at East 
Tennessee University noted that that there are methadone 
clinics operating on a cash basis handing out methadone without 
any other treatment, or buprenorphine ``pill mills.'' It is not 
acceptable that Federal taxpayer money be used to support 
programs that hand out these drugs for cash. Worse, Professor 
Melton testified that there was a dearth of good treatment 
programs. And what happens after the patient leaves the 
treatment program? What is being done to follow-up with 
patients to prevent relapses and put them on a path of real 
recovery?
    I fully recognize the importance of medication assisted 
treatment as a transition from street drugs and to prevent 
overdose from heroin. But relying on this as the one and only 
solution shouldn't be the strategy. As I recently heard Dr. 
McLellan, the former Deputy Director of ONDCP say, while there 
is an appropriate place for ``medication assisted treatment'' 
we should not turn a blind eye to the fact that there is also a 
tremendous amount of ``medication assisted addiction.'' It is 
not acceptable for Federal taxpayer money to be used to support 
treatment programs that lack evidence of effectiveness, or that 
define ``success'' merely as an individual with an addiction 
disorder using heroin fewer times per week than before 
treatment.
    I am calling for a patient-centered initiative with a goal 
of matching patients with the most appropriate care coupled 
with a focus on transition not just off of street drugs but 
eventual transition from opioids altogether. I hope to 
modernize our existing opioid addiction treatment system to 
ensure that the right patient gets the right treatment at the 
right time. It simply isn't true to present buprenorphine and 
methadone as opioid-free treatment. We do a tremendous 
disservice to those living with addiction disorders when we 
advance disingenuous double-talk and not state outright that 
buprenorphine and methadone are highly potent opioids.
    We are not going to end this opioid epidemic by increasing 
the use of opioids. We need an exit strategy that enables 
Americans to become opioid-free altogether. We can do better 
than addiction maintenance. We can and we must. I look forward 
to working with my colleagues and HHS as we explore new 
innovations for detoxification and treatment models to 
transition individuals off of all opioids into evidencebased 
counseling with non-addictive, non-narcotic behavioral and 
medication treatments.
    We don't do enough to help those addiction disorders. I 
believe in recovery. I believe in lives being restored so that 
every individual may live to their full God-given potential and 
do so drug free. I consider opioid maintenance as a bridge to 
cross over in addiction recovery, not a final destination. At 
this point, we've simply stopped building the bridge. We've not 
yet fully helped move those with addiction disorders beyond 
opioid maintenance. I seek to lay out a vision for recovery 
that includes complete withdrawal from opioids as an option. 
Once we lay out those goals, we can then move forward with 
research and clinical efforts, and boldly declare that we are 
no longer satisfied with the status quo of opioid maintenance 
only.
    To assist us today, the subcommittee will hear from some of 
the Nation's foremost professional and academic experts in the 
field of opioid addiction. Among the questions we hope these 
experts will address are: What can be done to incentivize 
individual compliance with prescribed treatment plans and 
reduce the risk of relapse? What should be the aim of treatment 
for opioid addiction: reduce the intake of illicit drugs by 
these individuals to more moderate levels? Or should the aim be 
to place patients on a path to detoxification and ultimately a 
full recovery, ending all illicit uses and removing the need 
for lifelong opioid maintenance recovery? To what extent is the 
increased prescribing of methadone for pain contributing to 
more overdose deaths? Are Medicaid and Medicare payments for 
the treatment of pain incentivizing doctors to prescribe 
opioids like candy for the treatment of pain?
    Today we have assembled some of the leading opioid 
addiction experts to get your thoughts about how to reverse 
this epidemic. We thank you for your expertise and look forward 
to hearing your testimony.

    Mr. Murphy. I now recognize Ms. DeGette for 5 minutes.

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

    Ms. DeGette. Thank you so much, Mr. Chairman. Before I make 
my opening statement, I want to announce today is Take Your 
Daughter to Work Day. My daughters tragically have grown up, 
but I have my daughter-for-the-day today, Paula, who is with 
us. Paula is a sixth-grader at Howard Middle School, and she is 
going to be with me today. She just told me she thought it 
would be really boring to come to the Capitol, but actually, so 
far she has found it to be fascinating. So I think she has a 
career ahead of her in politics, and we are glad to have her.
    I am also glad, Mr. Chairman, that we are having this 
hearing today. This is our second hearing in the series on this 
very important issue.
    This is a problem that touches all parts of the country and 
is growing. In 2013, 50 percent of all drug overdoses in this 
country were related to prescription pharmaceuticals. In 
Colorado, my home State, the rate of prescription overdose 
deaths has quadrupled in the last 10 years.
    I am happy to have this distinguished panel today who I 
hope can actually talk about, Mr. Chairman, what you suggest 
which is science-based treatments, and the best practices for 
treating this disease. All of our panelists have years of 
experience treating patients struggling with addiction, and I 
want to hear what all of you think is the most effective 
treatment.
    In our last hearings, we received considerable testimony 
from experts who told us that medication-assisted treatment, or 
MAT, can play a vital role in treating opioid addiction. 
Experts tell us that a combination of MAT and behavioral 
treatment, such as counseling and other supportive services, is 
the best way of treating opioid addiction. And, of course, 
there are several FDA-approved medications that have proven 
effective in treating opioid addiction.
    Now, Mr. Chairman, in your opening, you talked about 
science-based treatments, and I completely support that. You 
also talked about patient-oriented treatments, and I support 
that too. But in doing that, we need to recognize that while it 
is the goal to get everybody off of these drugs if possible, it 
is not always the case, and we need to look and see at the 
treatments that should be available for every patient. And so 
in an ideal world, we would have all the options available to 
every patient, and we should strive for that, but right now, 
MAT is not an available option for all patients. Dr. Bisaga, 
for example, will testify today that very few patients with 
opioid addiction receive treatments that have been proven the 
most effective, which includes access to MAT. What many 
Americans receive instead is a form of rapid detoxification 
from the drug, followed by an abstinence-only approach. Dr. 
Bisaga and others have called this method outdated and mostly 
ineffective, and even worse, I suppose, it could be dangerous 
because patients face a significantly elevated risk of dying by 
overdose if they relapse. So I want to ask questions about that 
today. Is it true that most Americans with opioid addictions 
don't receive the most effective treatments? Do they and their 
loved ones understand that? Is it true that many patients 
receive treatments that some experts suggest may be ineffective 
or dangerous? And finally, why is not MAT available as an 
alternative to all patients seeking treatment?
    From the perspective of the Federal Government, it is 
important to have science-based policy so that we are expending 
our resources on efforts that actually have a chance at 
success. And patients seeking treatment for opioid addiction 
should be apprised of the benefits and risks of alternative 
treatment approaches.
    Now, I understand that we need more study to predict which 
treatment alternatives will be effective for any given patient, 
and that is why I look forward to hearing from Dr. Seppala 
about the work he is doing at the Hazelden Betty Ford to 
collect data on factors. And by that way, in that vein, I want 
to recognize our former colleague, Mary Bono, who is here with 
us today, and a former member of this wonderful committee. So 
we are glad to have you here, Mary.
    I also recognize that we need more study regarding how to 
best treat opioid-addicted patients for the long-term, 
particularly people who want to taper off of the medications. 
And I certainly understand and support the desire to move 
toward medication-free recovery, but we also need to make sure 
that patients understand the risk.
    Finally, Mr. Chairman, much of what is being done to 
prevent and treat the opioid epidemic is happening on the State 
level. I am hoping in one of our future hearings that we can 
have witnesses come from the States to talk about their 
approaches. In Colorado, for example, we have the Colorado 
Consortium for Prescription Drug Abuse Prevention, which is a 
statewide coalition, and which is designing targeted programs. 
So when we have our hearing, I would like to have someone from 
Colorado.
    I think that this hearing will give us more information, 
and information and science-based decision making is really 
what we need to make effective use of our resources to 
combating this very, very serious problem of opioid abuse.
    And I yield back. Thank you.
    Mr. Murphy. Thank you.
    I now recognize the vice chairman of the full committee, 
Mrs. Blackburn, for 5 minutes.

OPENING STATEMENT OF HON. MARSHA BLACKBURN, A REPRESENTATIVE IN 
              CONGRESS FROM THE STATE OF TENNESSEE

    Mrs. Blackburn. Thank you, Mr. Chairman. And it is indeed 
Take Your Daughter to Work Day. And after I get to Nashville 
this afternoon, my daughter will go to an event with me. But 
she is an adult and, of course, has two children of her own, 
and we will not take them to that event.
    It is so good to see our former colleague, Mary Bono, here 
and I appreciate the good work that she continues to do on this 
issue.
    And, Mr. Chairman, I thank you for the hearing because this 
is a critical public health issue, and it does need our 
attention and our best efforts. And we are going to continue to 
look at this problem of prescription drug and heroin abuse 
because it has skyrocketed. And since '97, the number of 
Americans seeking treatment for addiction to painkillers has 
increased by 900 percent. That should give us all pause. Deaths 
related to heroin abuse increased 39 percent from 2012 to '13. 
That is a 2-year period of time. And while heroin use in the 
general population is still low, the number of people beginning 
to use it has steadily increased since 2007. And according to 
the National Institute on Drug Abuse, part of the explanation 
for the trend is a shift from the abuse of prescription pain 
relievers to heroin as a more potent, readily available and 
cheaper alternative to prescription opioids.
    Addiction and deaths due to overdose are just the tip of 
the iceberg in terms of medical consequences of this problem. 
One tragic consequence of the problem is neonatal abstinence 
syndrome. According to Dr. Stephen Patrick at Vanderbilt, in 
2013, Tennessee became the first State to make NAS a publicly 
reportable condition to the Department of Health. From 
information reported to our Tennessee Department of Health, we 
know the overall rate is 13 cases out of 1,000 births in the 
State of Tennessee. We can and we must do better for these 
babies. Our goal is to improve the Federal Government response 
to this crisis.
    Recently we heard from witnesses who expressed the State 
and local perspectives on this issue. Last year, we heard from 
a Federal panel of witnesses, including CDC, DEA, SAMHSA, NIH, 
and the Office of National Drug Control Policy, and today, we 
are rounding out this focus by hearing from you all who will 
give us the professional and academic perspectives. And we look 
forward to your testimony today, and we welcome you.
    And I yield back.
    Mr. Murphy. And nobody else on this side seeking final 2 
minutes, then I will turn towards Ms. Schakowsky for 5 minutes.

       OPENING STATEMENT OF HON. JANICE D. SCHAKOWSKY, A 
     REPRESENTATIVE IN CONGRESS FROM THE STATE OF ILLINOIS

    Ms. Schakowsky. Thank you, Chairman Murphy and Ranking 
Member DeGette, for calling this very important hearing on 
prescription drug and heroin abuse in the United States. Also 
thanks to our witnesses for coming here today to shed more 
light on this issue.
    This hearing could not be timelier. Increasingly, we are 
hearing reports of the toll this crisis is taking in 
communities across the country. And like myself, I am sure that 
every member of the subcommittee has heard stories from their 
constituents about the toll of prescription drug abuse and 
heroin abuse, the toll that it has taken in their districts.
    I have mentioned previously before this committee that I 
have a constituent, Peter Jackson, who tragically lost his 18-
year-old daughter, Emily, after she consumed a single Oxycontin 
tablet that she received from her cousin while visiting family. 
I look forward to hearing from our witnesses about the most 
effective ways to combat prescription drug abuse, to learn what 
additional steps we can take together to stop this crisis, and 
to prevent the further tragic loss of life.
    I also want to call attention to the impact that reducing 
discretionary spending will have on access to treatment and 
research on addiction. Just yesterday, House republicans 
approved budget allocations that will further cut discretionary 
spending for vital programs like SAMHSA and the National 
Institutes of Health. We have already heard--and we have 
already seen devastating cuts to these same programs. For 
example, the Substance Abuse Prevention and Treatment Block 
Grant within SAMHSA when adjusted for inflation has actually 
been cut by 25 percent in the last 10 years.
    While we are here today to discuss the most effective 
methods of treating addiction, without Federal funding for 
programs, patients will simply not have access to these 
services, and research on addiction and treatment of addiction 
will greatly suffer. That is just a fact. If we are serious 
about combating the opioid epidemic, it is incumbent that we 
provide strong Federal funding for the programs that patients 
and researchers rely on.
    And I want to yield the balance of my time to 
Representative Tonko.

   OPENING STATEMENT OF HON. PAUL TONKO, A REPRESENTATIVE IN 
              CONGRESS FROM THE STATE OF NEW YORK

    Mr. Tonko. I thank the gentlewoman from Illinois for 
yielding.
    Each and every year, I have spent Super Bowl Sunday in a 
soup kitchen, working alongside and serving individuals of the 
addiction recovery community. Why? Because I choose to land 
myself in the midst of real heroes. The individuals of the 
addiction recovery community, in my mind, through their 
courage, determination, and conviction are truly heroes. 
Bearing witness to the joy and rebirth that recovery has 
brought to their lives leaves me no doubt that complete 
recovery to a substance-free life is, and should be, our goal 
for every person who is struggling in the throes of addiction; 
a disease.
    While recovery remains the goal, it is nearly impossible to 
achieve without access to effective treatments. Science tells 
us that the most effective treatment available for opioid 
addiction is a combination of medication-assisted treatments, 
commonly known as MATs, and behavioral therapy. MATs might not 
be the preferred treatment for everyone, but they constitute a 
vital tool in our toolbox for treating opiate addiction. 
Unfortunately, MATs were available in only 9 percent of all 
substance use facilities nationwide in 2013, according to 
SAMHSA. While I will acknowledge the concerns that a reliance 
on MATs can raise, the immediate tragedy here isn't that some 
individuals won't be able to taper off maintenance medications, 
it is that most won't even be able to access an evidence-based 
treatment modality that has proven to be their best chance of 
easing the burdens of addiction and saving lives. Across my 
district, there are hundreds on waitlists to access this 
treatment. Every minute we delay, needed treatment costs lives. 
In just the time that we are having this hearing today, 5 more 
people will die from am opioid overdose, and 4 out of 5 
addicted to opioids will have no access whatsoever to 
treatment. This is totally unacceptable.
    No treatment option is perfect, and I strongly support 
further research that will help us create more effective 
treatments and cures that can rid us of addiction once and for 
all. For now though, our focus has got to be on curbing the 
epidemic, expanding treatment, savings lives, and giving people 
the stability they truly need to achieve recovery.
    I look forward to hearing the perspective of our witnesses 
on these pressing issues. And I yield back, Mr. Chair, the 
balance of my time.
    Mr. Murphy. Thank you. The gentleman yields back.
    And so we will go right into our witnesses and try and get 
all your testimony done before we have votes, and we will come 
back after votes too.
    We have with us today Dr. Robert DuPont, the President of 
the Institute for Behavior and Health. Additionally, Dr. DuPont 
was the first director of the National Institute on Drug Abuse. 
Welcome. Dr. Marvin Seppala, the Chief Medical Officer at 
Hazelden Betty Ford Foundation. As acknowledged, Ms. Bono is 
here with you today. Dr. Westreich is the President of the 
American Academy of Addiction Psychiatry. Dr. Anna Lembke is an 
Assistant Professor of Psychiatry and Behavioral Science at 
Stanford University Medical Center. And Dr. Adam Bisaga is an 
Associate professor of Clinical Psychiatry in the Department of 
Psychiatry at the College of Physicians and Surgeons of 
Columbia University, and and a research scientist at the New 
York State Psychiatric Institute. Finally, Dr. Patrice Harris, 
Elected Member of the American Medical Association, Board of 
Trustees. Dr. Harris has served on the Board of the American 
Psychiatric Association, and was an APA delegate to the AMA. I 
feel like I should get continuing education credits today----
    Ms. DeGette. I know.
    Mr. Murphy [continuing]. For being here.
    I will now swear in the witnesses.
    You are aware that the committee is holding an investigate 
hearing, and when doing so, has the practice of taking 
testimony under oath. Do you have any objections to taking 
testimony under oath? All the witnesses say they do not object. 
So 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 testimony today? All the witnesses decline. So in that 
case, will you all please rise, raise your right hand, and I 
will swear you in.
    [Witnesses sworn.]
    Mr. Murphy. Thank you. All the witnesses have answered in 
the affirmative. So you are now under oath and subject to the 
penalties set forth in Title XVIII, Section 1001 of the United 
States Code. I will call upon you each to give a 5-minute 
statement. Just pull the microphone close to you, press the 
button, and make sure the light is on. And try and keep your 
comments under 5 minutes.
    Dr. DuPont, you are recognized first.


STATEMENTS OF ROBERT L. DUPONT, M.D., PRESIDENT, INSTITUTE FOR 
   BEHAVIOR AND HEALTH, INC.; MARVIN D. SEPPALA, M.D., CHIEF 
 MEDICAL OFFICER, HAZELDEN BETTY FORD FOUNDATION; LAURENCE M. 
   WESTREICH, M.D., PRESIDENT, AMERICAN ACADEMY OF ADDICTION 
PSYCHIATRY; ANNA LEMBKE, M.D., ASSISTANT PROFESSOR, PSYCHIATRY 
    AND BEHAVIORAL SCIENCES, STANFORD UNIVERSITY SCHOOL OF 
MEDICINE; ADAM BISAGA, M.D., RESEARCH SCIENTIST, NEW YORK STATE 
PSYCHIATRIC INSTITUTE; AND PATRICE A. HARRIS, M.D., SECRETARY, 
        BOARD OF TRUSTEES, AMERICAN MEDICAL ASSOCIATION

                 STATEMENT OF ROBERT L. DUPONT

    Dr. DuPont. Thank you, Mr. Chair. It is a privilege for me 
to be with you.
    And let me pick up on some of the things that were 
presented just now. I think one of the most counterproductive 
approaches to the problem is to pick drug-free against 
medication-assisted treatment, and I think every time we do 
that we undermine dealing with the problem at all. We undermine 
public confidence, and I think it is contrary to what the 
public interest is and public health. And let me be very clear 
that I believe that full recovery is consistent with continuing 
to take medications for opiate dependence; buprenorphine, 
methadone, and naltrexone. The issue to recovery, to me, is not 
whether they are taking the medicine, it is are they using 
drugs, are they using alcohol, are they still involved in drug-
dependent behavior. And that is not compatible with recovery. 
And I am going to talk a little bit more about that issue about 
drug use in medication-assisted treatment, which I don't think 
is recovery, but I think that concept is very important, just 
like these patients taking psychiatric medicines is fully 
compatible with recovery. So I think that, to me, is a way to 
bring this together.
    And I also point out what Dr. Marv Seppala is going to talk 
about on the Hazelden Program, which brings together medication 
and the drug-free programs as the way into the future.
    And the last point I want to make before I really get 
started is to think about the elephant in the room when we are 
talking about recovery, and that is the 12-step programs; AA 
and NA, are an enormous part of what we are talking about, 
about getting well. We did a study, the first national study of 
physicians health programs, and we have now followed up with 
that 5 years after the mandatory monitoring. And 97 percent of 
those physicians were still in recovery 5 years after 
mandatory--and we asked them what part of the program was most 
helpful to you, and they were in very high quality treatment 
and many other services, by far the biggest percentage was 
participation in 12-step programs. That was what was most 
important to them. So I want to make sure at our hearing we 
understand the importance of that in terms of recovery.
    Now, my focus is on the users, and I want to make one point 
very clear. Opiate dependence is not like the common cold; it 
does not go away, it is a lifetime problem. A person who has 
opiate dependence is going to deal with that problem one way or 
another for his or her lifetime. If you don't understand that 
then the concept of treatment is confusing because you think 
you are going to be confusing because you think you are going 
to be fixed in treatment. People are not fixed in treatment 
with opiate dependence. Treatment can help them find their path 
to recovery, but treatment is not recovery, and it is really 
important that people are not fixed in any treatment, drug-free 
or medication treatment. It is a lifetime struggle, and that is 
a very important perspective on this.
    Now, my concern is that treatment does not match up with 
the disease. The treatment is always short-term. Even 
medication-assisted treatment, which conceptually goes on for a 
lifetime, has very high drop-out rates, very rapid--patients 
drop out of the program for medication-assisted treatment. And 
the other thing is a high percentage of people in medication-
assisted treatment continue to use opiates and other drugs 
while they are in the program. That is very important to notice 
that and pay attention to that. But even more important, and 
the thrust of my testimony, all of it is accountability for 
treatment. What are the results during treatment? What 
percentage of the patients are continuing to use drugs? How 
much retention is there? What is the retention curve of the 
program? How long do they stay in treatment? And when they 
leave, are they any better off than they were when they came 
in? Those questions need to be asked and answered in a 
systematic way.
    The other thing I pick up on the chairman's statement about 
the standard. What we want is recovery. That means no use of 
alcohol and other drugs, including opiates, not just opiates 
but all drugs. That is what recovery is. It requires that. And 
what I am proposing and encouraging the committee to do is to 
look long-term, because the nature of the disorder is long-
term. And I use the 5-year recovery standard. Start with a 
person who enters treatment. Where is that person in 5 years? 
And you can look at any program; drug-free or maintenance--or 
medication-assisted, and ask the question how good is this 
program at getting a person into a stable recovery. That is one 
standard for all treatments, and it gets you focused on the 
long-term. And when we do that in this country, including in 
the Federal Government, the whole game changes and we have a 
mechanism to improve treatment. Treatments can all compete on a 
level playing field to achieve that goal.
    So that is my testimony. Thank you very much.
    [The prepared statement of Dr. DuPont follows:]
    
    
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    Mr. Murphy. Thank you. Thank you very much.
    Dr. Seppala, you are recognized for 5 minutes.

                 STATEMENT OF MARVIN D. SEPPALA

    Dr. Seppala. Chairman Murphy and Ranking Member DeGette, 
thank you very much for inviting me to participate in this 
important hearing, and for your leadership in addressing the 
crisis of addiction to opioids in this country.
    My name is Marv Seppala, I am the Chief Medical Officer of 
the Hazelden Betty Ford Foundation. I attended Mayo Medical 
School, and have been practicing in the addiction field for 27 
years. On a personal note, I have also been in long-term 
recovery from addiction since age 19.
    The Hazelden Betty Ford Foundation is the Nation's largest 
nonprofit addiction treatment provider, and we have been around 
since 1949. We have 16 sites in 9 States. We offer prevention 
and recovery solutions nationwide for youth and adults. At our 
facilities, we have seen a pronounced increase in the number of 
patients with opioid use disorders, paralleling the grim 
stories you have probably been hearing about in your districts 
for some time now. At our residential youth facility, for 
example, opioid dependence rates increased from 15 percent of 
patients in 2011 to 42 percent in 2014. That is a dramatic 
rise, and this is an especially difficult addiction to treat. 
Individuals dependent on prescription pain medications and 
heroin often face unique challenges that can undermine their 
ability to stay in treatment and ultimately achieve long-term 
recovery. They are hypersensitive to pain and more vulnerable 
to stress. Their anxiety, depression, and intense craving for 
these drugs can continue for months, even years, after getting 
free from opioid use. They experience a strong desire to feel 
normal again, to escape what seems like a permanent state of 
dysphoria, which puts them at high risk for relapse. They are 
also at higher risk of accidental overdose during relapse 
because they no longer have the tolerance to handle the same 
doses they were taking prior to treatment. In other words, with 
opioids, unlike other drugs, relapse often means death.
    In 2012, we launched a new protocol to treat opioid 
addiction, the Comprehensive Opioid Response with 12 Steps, or 
COR-12 as we call it. Our approach is grounded in the 
traditional 12-step facilitation model and based on abstinence, 
but it now also utilizes the safest live-saving medications 
that keep patients engaged in recovery long enough to achieve 
lasting sobriety.
    We don't see a conflict in utilizing medications and 
pursuing abstinence, just as Bob described. Even when 
medications are part of our protocol, abstinence is still the 
objective. In fact, one might call it a third way because it 
strikes a reasonable commonsense balance between those who see 
medication assistance and abstinence as diametrically opposed.
    Our COR-12 Program includes changes to traditional group 
therapy, additional patient education about opioids, and the 
option now of medication assistance. We utilize extended-
release naltrexone, Vivitrol, as well as buprenorphine/
naloxone, or Suboxone, to help engage patients long enough to 
complete treatment, and then become established in solid 12-
step recovery. The highest risk period for relapse is the first 
12 to 18 months after treatment, so we prefer to have our 
patients involved and on medication in outpatient care 
throughout this extended period. And our goal is to discontinue 
medication as our patients become established in long-term 
recovery.
    While our clinicians recommend which medication is 
appropriate, the final decision is up to the patient, and about 
\1/3\ of our COR-12 patients elect to use no medication. 
Indeed, medication only addresses the biologic aspect of 
addiction. Our broader measures treat the psychological, 
social, and spiritual components to improve psychosocial 
functioning, enrich relationships, and foster a healthier 
lifestyle. And those are the keys to recovery that last.
    Our COR-12 Program has resulted in more patients completing 
residential treatment, and a reduction in overdose deaths after 
treatment. While the research study of COR-12 is ongoing, and 
we do not have full results yet, we do know that COR-12 
patients stay in treatment longer. Our atypical discharge rate, 
those who leave treatment early, for our general population is 
13 \1/2\ percent, and for those with opioid dependence who 
don't enter this program, it is over 22 percent. However, in 
this program, it is only 7.5 percent.
    Now, based on our early positive results, we plan to 
continue paving the way for others to use both scientific and 
spiritual solutions to engage more people in treatment, save 
lives, and ultimately help more people get into long-term 
recovery.
    I would also like to emphasize the need to educate a wider 
culture about the dangers of opioid overprescribing. The 
troubling trends began to emerge in the late '90's after the 
FDA approved Oxycontin and allowed it to be promoted to primary 
care physicians for treatment of common aches and pains. 
Education campaigns often funded by opioid manufacturers 
minimized risks, especially the risk of addiction, and 
exaggerated benefits to using these opioids long-term for 
common problems. When prescribing on a short-term basis to 
treat moderate to severe acute pain, opioids can be helpful, 
but when these are highly addictive medications that are taken 
around the clock for weeks, months, and years, they may 
actually produce more harm than healing. An increasing body of 
research suggests that for many chronic pain patients, opioids 
are neither safe nor effective. Over time, patients often 
develop tolerance, leading them to require higher and higher 
doses, which ultimately can lead to quality of life issues and 
functional decline.
    It should be noted that doctors didn't start 
overprescribing out of malicious intent, but rather out of a 
desire to relieve pain more compassionately.
    Now, we have a culture that seeks opioid medication for 
pain relief, not just for physical pain but also to numb 
psychic pain. Some of these patients have a significant risk 
for the development of addiction in a culture that promotes 
quick fixes, instant gratification, and escapism. Medical 
professionals need further education about the proper use of 
opioid medications and their risks. The general public also 
needs such education to prove recognition of risk, and 
limitations of these powerful, dangerous medications. It is 
time now to address opioid overprescribing and overuse without 
stigmatizing pain. This crisis deserves the attention you are 
providing today, and requires a substantial response.
    Thanks again for having me here, and for your leadership. I 
look forward to answering your questions.
    [The prepared statement of Dr. Seppala follows:]
    
   
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    Mr. Murphy. Thank you, Doctor.
    Now, Dr. Westreich, you are recognized for 5 minutes.

               STATEMENT OF LAURENCE M. WESTREICH

    Dr. Westreich. Mr. Chairman, members of the committee, 
thank you very much for inviting me to speak to you today about 
treatment for opioid addiction. Dr. Murphy, before I start, I 
would like to say that as a psychiatrist specializing in 
addiction, I am particularly appreciative of the clinical 
awareness you have imparted to the Helping Families in Crisis 
Act, which will focus resources on helping our patients. I am 
Board certified in general psychiatry, addiction psychiatry, 
and forensic psychiatry, and I serve as president of the 
American Academy of Addiction Psychiatry, which is a 
professional organization for psychiatrists who specialize in 
the treatment of addiction and other mental illnesses.
    My primary professional focus is on the clinical treatment 
of addicted people. I trained at Bellevue, where I worked for 
many years and continue to teach, and I treat people addicted 
to opioids in my offices in Manhattan and in New Jersey, where 
I live. I know this committee understands very well the lethal 
nature of opioid addiction. You don't need us to tell you about 
that. My main goal in speaking with you today is to underline 
what you have already heard; opioid-addicted people need access 
to a broad range of treatments for opioid addiction. This must 
include access to medication-assisted therapy, and treatment 
for co-occurring psychiatric disorders. I have treated 
homeless, heroin-injecting senior citizens, college students 
who snort Oxycontin, and practicing attorneys who must take an 
opioid pill every few hours in order to continue seeing their 
clients. The death and destruction I have seen due to opioid 
addiction is profoundly disturbing, but thankfully with 
appropriate treatment, the more common return to health, the 
workplace, and family, is what keeps most of us doing the 
clinical work which helps addicted people in their search for 
recovery.
    Part of that clinical work includes full treatment for what 
is ailing the addicted person. Research demonstrates that the 
opioid-using person often has a co-occurring mental illness, 
like major depression, bipolar disorder, or PTSD. Sometimes the 
opioid user is self-medicating uncomfortable mood states or 
anxiety, or just has difficulty soothing him or herself. All 
these circumstances can increase the risk for relapse, and 
require sophisticated and individualized psychiatric evaluation 
and treatment. Research makes it clear that prescribing the 
appropriate effective medication to help the patient with 
craving, along with talk therapy and treatment for a co-
occurring psychiatric disorder, gives the addicted person the 
best possible chance for recovery.
    That sophisticated treatment system must include access to 
well-trained clinicians who can select between the available 
psychosocial treatments like relapse prevention therapy, 
cognitive behavioral therapy, medications like buprenorphine, 
methadone, and naltrexone, and mutual support groups like 
Narcotics Anonymous. For many, mutual support groups like AA or 
NA can be extremely helpful, but they are not treatment, nor do 
they claim to be. They are support groups which can be 
lifesaving for some, and not so much for others. As you have 
heard, the available research has not provided us with a silver 
bullet that works for all opioid addiction. Rather, the data 
tell us that some treatment works for some opioid addicts some 
of the time. Others may respond to a very different approach. 
That is one reason we clinicians must have all available arrows 
in our quivers. We must have the skills and training for a 
broad array of approaches to meet the treatment needs of each 
patient. Quite often, using a treatment--team approach that 
includes psychologists, social workers, nurses and counselors, 
is critical to therapeutic success.
    The wide variety of personal choices addicted people make 
about treatment is yet another reason for supporting the full 
spectrum of treatment possibilities from medication-assisted 
treatments with buprenorphine and methadone, to opioid blockers 
like naltrexone, to relapse prevention therapy. Some patients 
demand to be treated without medications, while others clearly 
want and need medication to control their craving. And they 
also require more specific psychiatric treatment for any co-
occurring disorders.
    Use of buprenorphine and methadone, which are both opioids 
like heroin, can be controversial. When I talk to opioid-
addicted people and their families, I sometimes, but not 
always, recommend tapering or maintenance with buprenorphine or 
methadone. The question is not whether the medication has side 
effects; all medications do, but whether the risk is worth the 
benefit. Patients and their families need to know that 
detoxification treatment and drug-free counseling are 
associated with a very high risk of relapse. As with other 
medical conditions, the relevant question about whether a 
medication is worth the risk is the following. Compared to 
what? Is taking buprenorphine or methadone better than dying 
from an overdose, better than contracting HIV or Hepatitis, 
flunking out of school, losing a marriage, losing a job? One-
size treatment does not fit all, and different patients may 
need different treatments. But the very good news in this 
situation is that people who are able to stop their use of 
illicit drugs, whether through psychotherapeutic interventions, 
medications, and/or help from NA, or most likely some 
combination of the above, can return to vibrant and productive 
lives. It is that return to physical and emotional health, 
which I find so gratifying; it empowers me to help my patients 
to keep trying.
    Before I stop, let me reiterate my main point, and what I 
know you have heard from many others. Opioid-addicted people 
need access to a broad range of treatments for addiction. This 
must include medication-assisted treatment, and treatment for 
co-occurring psychiatric disorders.
    Thank you very much for inviting me today.
    [The prepared statement of Dr. Westreich follows:]
    
    
    
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    Mr. Murphy. Thank you very much.
    Dr. Lembke, you are recognized for 5 minutes.

                    STATEMENT OF ANNA LEMBKE

    Dr. Lembke. Thank you for inviting me today to these 
hearings.
    The main point I would like to make today is simple. We 
don't just have an opioid abuse epidemic or an opioid overdose 
epidemic, we have an opioid overprescribing epidemic.
    Doctors are a major pipeline of misused and diverted 
prescription opioids, and contrary to what is commonly 
believed, doctors who treat addiction are not the main source 
of the problem.
    The methadone that accounts for 40 percent of single drug 
opioid pain reliever death is almost entirely in the form of 
pills prescribed for the treatment of pain, rather than coming 
from methadone maintenance clinics that treat heroin-dependent 
patients. We, thus, need to think broadly about the problem 
with changing the behavior of all physicians and not just those 
who treat addicted patients.
    I was pleased to see the education of providers was 
identified as one of three priority areas in the report issued 
last month from the Department of Health and Human Services, 
which called prescribers ``the gatekeepers for preventing 
inappropriate access.'' But providing educational material on 
safe opioid prescribing, even if it is free and readily 
available, won't be enough. To change doctor prescribing 
behavior we need first to acknowledge the enormous incentive to 
prescribe opioids, and the disincentives to stop prescribing. 
Many doctors are afraid that a patient will sue them or 
complain about them if they don't prescribe opioids, even when 
the doctor knows the opioid is harming that patient. Also, no 
insurer questions me when I prescribe Vicodin for pain, but if 
I want to prescribe Suboxone to help an addicted patient stop 
taking Vicodin, I typically have to spend hours fighting an 
insurance company to get the prescription approved. Despite the 
Mental Health Parity and Addiction Equity Act that Congress 
passed by a huge bipartisan margin in 2008, many insurers still 
resist reimbursing for addiction treatment.
    The solution to this problem lies in giving doctors 
tangible incentives to prescribe more judiciously, such that 
neither pain nor addiction is undertreated.
    Today, I focused on three areas where I believe this 
Congress can make a positive difference. Number one, require 
revision of healthcare quality measures. Number two, 
incentivize use of prescription drugs monitoring programs. And 
number three, scrutinize accreditation organizations and 
regulatory agencies.
    First, require revision of healthcare quality measures. The 
Centers for Medicare and Medicaid Services and the Joint 
Commission exert enormous control over how doctors practice 
medicine today. Their quality measures set the standard of 
care. In the 1990s, they urged doctors to prioritize pain 
treatment, and that is what we did. Prescriptions for opioids 
skyrocketed, not always to the benefit of our patients.
    CMS and the Joint Commission need to link quality measures 
to treatment outcomes for patients with addictions. This will 
incentivize hospitals and clinics to create an infrastructure 
to screen for and treat opioid addiction.
    Quality measures should also limit excessive prescribing of 
multiple drugs to the same patient, especially of controlled 
medications. A younger person with no objective evidence of 
disease should not be on 10 different medications, yet I often 
see this, and the medications frequently include an assortment 
of stimulants, sedatives, and opioids. Also, far too many 
patients are on a prescription of benzodiazepines at the same 
time as opioids, which greatly increases their risk of 
overdose.
    Finally, CMS and Joint Commission quality measures should 
not be linked to patient satisfactions with opioid prescribing. 
Illness recovery, not patient satisfaction surveys should be 
the arbiter of quality care. Doctors are not waiters, and 
opioids are not items on a menu.
    Second, incentivize use of prescription drug monitoring 
programs. Prescription drug monitoring programs allow doctors 
to see all the controlled medications prescribed to a patient 
beyond just the ones that they prescribe. When physicians make 
use of prescription drug monitoring programs, prescription drug 
misuse decreases. Monitoring programs don't merely limit access 
to opioids when they should not be prescribed. They allow for 
patients who really need them to get them. The question is how 
to get more doctors to use these databases. By some reports, 
only 35 percent of prescribers use these databases. Here are 
some ways to incentivize doctors to use prescription drug 
monitoring programs. Make it a billable medical service. 
Mandate education on use of PDMPs when physicians apply for DEA 
licensure. Amend privacy laws such as 42 C.F.R. so that 
healthcare providers can freely communicate with each other 
around issues related to prescription drug misuse.
    Third, scrutinize accreditation organizations and 
regulatory agencies. The Joint Commission, the accreditation 
organization which sets standards for hospitals, was 
instrumental in socializing doctors to liberally prescribe 
opioids for pain. The Joint Commission's campaign on treating 
pain was funded in part by Purdue Pharma, whose main product is 
Oxycontin. I do not think Congress should allow a major 
healthcare accreditation body like the Joint Commission to take 
money from the pharmaceutical industry.
    In 2012, the Food and Drug Administration wisely 
rescheduled hydrocodone products to Schedule II, but the very 
same week, the FDA approved the use of Zohydro, a longer-acting 
opioid with high abuse potential, similar to Oxycontin. The 
FDA's own advisory panel recommended not to approve Zohydro, 
yet it was approved anyway. Why? Do we really need one more 
high-risk opioid medication on the market? It seems to me like 
trying to empty a bathtub with a thimble, while filling it with 
a firehose.
    Furthermore, the FDA should live up to its commitment to 
stop approving non-abuse deterrent formulations of opioids, 
which it did not do when it approved Zohydro. And doctors and 
patients need to understand that abuse-deterrent formulations 
make it harder to crush and snort and inject an opioid, but 
they do not prevent ingesting opioids orally at high doses, 
becoming physiologically dependent on and addicted to them, and 
overdosing on them.
    To sum up, Congress can push back against the opioid 
epidemic by requiring revision of healthcare quality measures 
to reduce overprescribing, incentivizing use of prescription 
drug monitoring programs, and scrutinizing accreditation 
organizations and regulatory agencies. All 3 approaches will 
save lives and improve the practice of medicine at the same 
time.
    Thank you again for this opportunity to testify, and for 
your leadership in addressing this public health epidemic.
    [The prepared statement of Dr. Lembke follows:]
    
    
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    Mr. Murphy. Thank you, Doctor.
    Now, Dr. Bisaga, you are recognized for 5 minutes.

                    STATEMENT OF ADAM BISAGA

    Dr. Bisaga. Thank you, Chairman Murphy, Ranking Member 
DeGette, and members of the committee, both for holding this 
hearing and for inviting me to speak to you today.
    My name is Adam Bisaga. I am a scientist, working on 
developing new medication strategies to treat opioid 
dependence. I am also educating physicians nationally with 
regards to safe and effective use of these mediations, and I 
have been practicing addiction psychiatry for the past 20 
years.
    I would like to speak on the opioid epidemic from the 
perspective of medical management. And I want to point out how 
our current drug treatment system in the United States is 
outdated; that it does not reflect the scientific progress we 
have made in the past 50 years. Our current system is built on 
the model for treating patients with alcoholism, and it is not 
capable of responding to the unfolding opioid epidemic.
    Opioid addiction is manifested by the compulsive use of 
opioid painkillers or heroin. Patients have abnormal activity 
in several brain regions, and experience powerful urges to use 
that they find very difficult to control. This abnormal brain 
activity can persist for months throughout the abstinence, 
driving high relapse rates. Medications can stabilize opioid 
receptors in the brain; reducing craving, eliminating 
withdrawal, and blunting the patient's ability to feel the 
effects of heroin. These medications work best in conjunction 
with psychosocial therapies to produce long-lasting abstinence. 
This approach has success rates similar to treatments we have 
for many other medical and psychiatric disorders. However, in 
stark contrast, the treatment for most other disorders, very 
few patients with opioid addiction receive evidence-based 
treatment.
    The traditional approach of a brief detoxification followed 
by therapy-only approaches has no evidence for treating 
effectively opioid addiction. In addition, this approach can be 
very dangerous. Patients that do not receive medications to 
block the effects of relapse face an elevated risk of dying 
when they relapse. Certainly, all of us have witnessed it on 
too many occasions.
    So we have three FDA approved medications; methadone, 
buprenorphine, and naltrexone. Methadone activates opioid 
receptors in the brain and blocks the effects of heroin or 
painkillers. Methadone-treated patients use less heroin, have 
fewer medical complications, and have improved social and work 
functioning. In other words, they are able to lead a normal 
life. Methadone is the most effective medications we have, 
however, it is a potent medication, and can cause sedation or 
even death. Therefore, dispensing of methadone is highly 
regulated.
    Buprenorphine works similarly to methadone, but only 
partially activates opioid receptors. It also protects patients 
from overdose risk. Because buprenorphine is safer than 
methadone, less monitoring is needed and it can be prescribed 
by the doctors in their offices.
    Naltrexone, the last medication, is available as either a 
daily tablet or a monthly injection. Naltrexone works 
differently from methadone and buprenorphine. It completely 
blocks opioid receptors, and it is used after detoxification to 
prevent relapse. It has no abuse potential, there is no 
withdrawal when it is stopped.
    Treatment with medication works best as a maintenance 
intervention, without a predefined length of treatment. There 
is no scientific evidence showing benefits to limiting the time 
someone is treated with medication. Opioid addiction is a 
chronic brain disease, and that responds best to chronic 
treatment.
    Methadone, buprenorphine, and naltrexone have all different 
mechanism of action. In this era of personalized medicine, 
patients respond best to medication that are tailored to their 
individual needs. All of these medications are needed to 
adequately address the opioid epidemic. Every American should 
have access to these medications, and with the help of a 
physician, help make an informed decision about their path to 
recovery. Regulations should be put in place to make 
buprenorphine and naltrexone available at every treatment 
center working with patients addicted to opioids.
    More than 100 of individuals, many of them young adults, 
die of opioid overdoses every day. Medication-assisted 
treatment is the best way to reduce the number of deaths on a 
large scale. Addiction is a treatable disorder, and a joint 
effort of health professional, community advocates, and 
policymakers is urgently needed to reverse this tragic trend.
    Thank you for the opportunity to testify.
    [The prepared statement of Dr. Bisaga follows:]
    
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    Mr. Murphy. Thank you. Appreciate it.
    We are going to try and get Dr. Harris' testimony in, then 
we are going to run to go vote and come back.
    So you are recognized for 5 minutes.

                 STATEMENT OF PATRICE A. HARRIS

    Dr. Harris. Thank you. Good morning, Mr. Chairman and 
Ranking Member, and esteemed members of the subcommittee. I am 
honored to testify today on behalf of the American Medical 
Association. My name is Dr. Patrice Harris. I am Secretary of 
the AMA Board of Trustees. I am also the Public Health Officer 
for Fulton County, which includes Atlanta, and I am a 
practicing psychiatrist with experience in addiction.
    We are indeed in the midst of an epidemic. Physicians are 
deeply disturbed about the rise in overdoses and fatalities 
from prescription opioids, as well as the rapid increase in 
deaths from heroin-related overdoses. The numbers are sobering 
and unacceptable.
    The AMA is working on a number of fronts with many other 
groups to develop recommendations and implement specific 
strategies to confront this public health crisis. Physicians 
are stepping up and taking responsibility to prevent and reduce 
abuse, misuse, overdose, and death from prescription opioids. 
We also need to make sure that our patients who experience pain 
receive the treatment they need. With opioids, if clinically 
appropriate, and that patients who have an opioid use disorder 
have timely access to affordable, comprehensive treatment.
    These are complex problems and there is no one solution. A 
multifaceted, public health strategy is needed. There are key 
components to this strategy. First, physicians must continue to 
amplify our efforts to train and educate ourselves to ensure 
that we are making informed prescribing decisions, considering 
all available treatment options for our patients, and making 
appropriate referrals for our patients with substance use 
disorders. As part of the prescriber clinical support system 
for opioid therapies funded by SAMHSA and administered by the 
American Academy of Addiction Psychiatry, the AMA is developing 
new training materials on responsible opioid prescribing, 
including a focused educational module on opioid risk 
management for resident physicians.
    Patients in pain deserve compassionate care, just like any 
other patient we treat. The dialogue must change to reduce the 
stigma that is associated with pain. We need to increase 
insurance coverage for evidence-based alternative, 
multidisciplinary, non-drug pain management therapies. At the 
same time, we need to support access to opioid-based therapies 
when clinically appropriate.
    Opioid use disorder is a chronic disease that can be 
effectively treated, but it does require ongoing management. 
Physicians need more resources so that evidence-based 
treatments such as medication-assistant treatment in 
conjunction with counseling and other behavioral therapies and 
interventions are more available and accessible to all of our 
patients. There are not enough programs and many are not 
affordable.
    We strongly support lifting the cap and expanding the 
number of patients that office-based physicians can treat with 
buprenorphine and Suboxone, which are major tools in treating 
opioid use disorder.
    Naloxone has saved thousands of lives across the Nation, 
and we strongly support increasing access to it. We encourage 
physicians to prescribe naloxone to their at-risk patients, but 
barriers still exist to using this effective drug to prevent 
overdose deaths.
    Now, one way to reduce one of these barriers is passage of 
Good Samaritan laws so that healthcare professionals, first 
responders, friends, family members, and bystanders who see 
someone who had overdosed can help save a life without fear of 
liability.
    Last, prescription drug monitoring programs can be a 
helpful clinical tool. However, to be most effective and used 
more often, PDMPs need to be real time, interoperable, and 
available at the point of care as part of a physician's 
workflow. In order to get to this point though, Congress needs 
to fully fund these programs so that States can modernize and 
fully fund and staff them.
    So in summary, we know that it is up to our profession to 
provide the leadership necessary to confront this epidemic, and 
we commend this committee's leadership and look forward to 
working with you and other stakeholders to promote evidence-
based solutions. Our patients deserve no less.
    Thank you.
    [The prepared statement of Dr. Harris follows:]
    
    
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    Mr. Murphy. Thank you, Dr. Harris. And thank you to the 
panel.
    We are in the middle of votes, so we are going to break 
here. It is going to take us about half an hour or so for 
votes. We will come back.
    I just wanted to leave one sobering statistic I have here 
about this. In North America, the number of deaths from plane 
crashes between 1975 and today was 42,495. 1975 through today. 
For the United States, the number of drug overdose deaths last 
year was 43,000. If we were here having a hearing on plane 
crashes, we would need an arena to handle the media. What a sad 
day it is with 43,000 people died in this country last year. I 
feel that we need to have people understand the severity of 
that.
    I thank this panel for your testimony. We will come back 
and ask you questions in a few minutes. Thank you.
    [Recess.]
    Mr. Murphy. All right, we are going to return to our 
hearing here, and as members come in, we will put them in the 
queue.
    So let me start off here. I want to ask a question here. 
Dr. Seppala, a Federal policy prohibits Medicaid matching funds 
being used at inpatient facilities with more than 16 beds whose 
patient roster is more than 51 percent people with severe 
mental illness, and for individuals between the ages of 22 and 
64. Does this affect inpatient substance use disorders clinics 
as well when they have those limitations?
    Dr. Seppala. It sure would, absolutely. Any population that 
is restricted in that manner is not going to get adequate 
treatment.
    Mr. Murphy. So again, making sure we have options 
available, that is a barrier that we need to eliminate.
    Dr. Seppala. Yes, increasing options for addiction 
treatment is really necessary in this country. We don't have 
adequate treatment to address this problem, but we also have a 
public health information problem because, if you look at the 
data from SAMHSA, you will see that over 95 percent of the 
people with addiction don't even know they have it. So that is 
where the initial problem lies. And then of that small group 
that seeks treatment, the biggest problem is access.
    Mr. Murphy. Now, Dr. DuPont, I want to show you a poster 
here. According to the National Institute on Drug Abuse, for 
patients treated with opioid addiction with buprenorphine, 
there is a 92 percent of relapse with an illicit opiate within 
8 weeks after stopping treatment. But look at the increases 
here--this line is buprenorphine--from 2003 to 2012, and it has 
gone up even higher now. Methadone rates have remained fairly 
flat, and heroin rates have increased slightly over this time. 
So I am wondering, given these statistics, and given the huge 
relapse rate with 92 percent, relapse with an illicit opiate 
within 8 weeks after stopping treatment, are we doing enough to 
hold treatment programs accountable to make sure that they are 
getting people the additional treatments to get them on the 
road to recovery?
    Dr. DuPont. Well, that is very important information, 
absolutely, and to me, it shows that buprenorphine or methadone 
are not magic bullets, but they are very attractive to many 
patients and they bring a lot of people into treatment, and 
that is a good thing. I think the question, to me, is what 
happens to them then? And if they just go out and leave the 
program, nothing very good is happening. I am excited about the 
possibility of having a longer-term perspective on the 
buprenorphine patients, and helping them over a longer period 
of time. But the answer is, as you show there, that most stay a 
very short time and the outcome when they leave is that they 
relapse to the opiates.
    Mr. Murphy. And I want to make sure we are all on the same 
page, because what I am pushing for is I want to make sure we 
have a standard here that has hopes of getting people off of 
substances. And I recognize, like any other field, we can't 
reach 100 percent, but our goals should never be less than 100 
percent. But there is a big overlap also with people with 
mental illness.
    Dr. Westreich, so people with mental illness and severe 
mental illness who are actually seeking some substances to numb 
the effects or self-medicate. I see a lot of these in the 
military with folks, and of course, it makes a bad situation 
worse. But then when you have someone who is now addicted, and 
we are trying to wean them off, I would like to think that this 
is not just a matter of substituting an opiate with 
buprenorphine or methadone as a replacement as a road of 
treatment, but really thinking in terms of should they be on 
another medication, a psychotropic drug, something else to 
treat the underlying mental illness. Is this an appropriate 
hypothesis? And two, are we doing this, and if not, why not?
    Dr. Westreich. First of all, I think it is absolutely an 
appropriate hypothesis, and I don't think we are doing it 
enough.
    I think the point is that people who have addictive 
disorders as well as another mental illness need to have very 
sophisticated clinicians who are trained in being able to 
recognize psychiatric symptoms and what they mean. Do they mean 
that the person is simply medicating some uncomfortable 
symptoms? Do they mean that the person has got a freestanding 
psychiatric illness, which must be treated with psychotropic 
medications, or some combination of the above? And so this 
speaks to the training of psychiatrists, psychologists, social 
workers, counselors who need to be trained to recognize mental 
illness symptoms and treat them effectively.
    Mr. Murphy. And we have heard repeatedly in this committee 
that the huge shortage of psychiatrists, psychologists, 
especially child/adolescent ones, to deal with this issue. But 
another concern we have heard is from States that there are 
limitations on--they have funds for substance abuse, and they 
have funds for mental illness, and oftentimes they can't use 
those together.
    Anybody want to comment on that of what we should be doing 
to make sure that they have maximum flexibility in the States? 
Can anybody comment on that? Dr. Bisaga?
    Dr. Bisaga. I think those very often is more of a norm than 
an exception that they go together. So keeping them separate, 
in separate pools of money, doesn't really make sense from a 
clinical perspective. I think we are much more effective when 
we are integrating treatment for mental illness and substance 
abuse by the same provider in the same setting. This is the way 
to have better outcomes.
    Mr. Murphy. Thank you. Anybody else want to comment? Yes, 
Dr. Seppala?
    Dr. Seppala. In our residential settings, in our youth 
settings, so it is about age 14 to 24, over 95 percent of our 
population enters treatment with a coexisting diagnosis of a 
mental illness. In our adult populations, again, a residential 
not outpatient setting, it is over 75 percent. So what we are 
seeing is comorbid psychiatric illness with addiction in our 
treatment settings. It is the norm. We have to treat both.
    Mr. Murphy. Thank you.
    Ms. Schakowsky, you are recognized for 5 minutes.
    Ms. Schakowsky. So I have never seen that chart before and, 
you know, you first look at the chart and you think that 
buprenorphine is a bad idea. I mean that is how it looks. So I 
wondered if anyone----
    Mr. Murphy. Yes, I am just saying we are doing more of it, 
but----
    Ms. Schakowsky. So maybe Dr. Bisaga can speak to that?
    Dr. Bisaga. Well, you know, obviously, this is a very 
complex problem. You know, we see increasing rates of 
buprenorphine prescribing because we have an epidemic and we 
are trying to expand the number of people that are treated with 
this medication. So it tells us a lot of things. It is true 
that not every buprenorphine treatment program is to the best 
standards, but that shouldn't really stop us from trying to 
expand access. We still have a shortage of providers that are 
trained to deliver this treatment. But if this chart had also a 
number of people addicted to painkillers, this line would 
probably go down, which I think speaks something about at least 
the beginning of making a----
    Ms. Schakowsky. But it does it mean that methadone is 
better, or----
    Dr. Bisaga. Well, you know, when you compare methadone with 
buprenorphine in a similar situation, methadone is a little bit 
more potent as a medication, but because it is such a, you 
know, difficult medication to use, it cannot be really widely, 
you know, as easily disseminated to the community as 
buprenorphine, and that is why we are pushing for the 
buprenorphine, again, as a first step of engaging people in 
treatment, protecting them from overdose, and then engaging 
them in the long-term psychosocial recovery-oriented treatment.
    Dr. Lembke. Yes, I would just add that this is a really--I 
just would add a really important difference between 
buprenorphine and methadone is that the methadone--the overdose 
risk with methadone is very high, whereas the unique 
pharmacology of buprenorphine makes it very unlikely for people 
to overdose on it.
    Ms. Schakowsky. Right.
    Dr. Lembke. And so for that reason, there is a huge 
advantage in using buprenorphine, especially since one of the 
primary things we are trying to stop is the number of people 
who are dying due to opioid overdose.
    Ms. Schakowsky. So also let me understand, on the panel, is 
there anybody who doesn't think that the combination of meds 
and psychosocial treatment, that one or the other itself is the 
way to go? No, oK.
    So let me ask Dr. Lembke. Unfortunately, there are a number 
of barriers then for people to get medication, assisted 
treatment, MATs, and one of the barriers is insurance coverage. 
And according to the American Society of Addiction Medicine, 
Medicaid coverage for MAT varies greatly from State to State, 
the chairman was talking about that, with some States not 
covering all FDA-approved medications, imposing prior 
authorization requirements, and fail-first criteria that 
require documentation that other therapies were ineffective. I 
wondered, Dr. Lembke, if you have experienced these issues in 
your practice, both of Medicaid and private insurers?
    Dr. Lembke. So that is very common with both Medicaid and 
private insurers that when you try to get coverage for 
addiction treatment, they give you the huge runaround, you have 
to talk with somebody on the phone for hours regarding medical 
necessity, whereas that is not true if you are prescribing a 
pharmacologically identical medication, or a very similar 
medication, for the treatment of, for example----
    Ms. Schakowsky. So what does that----
    Dr. Lembke [continuing]. Pain.
    Ms. Schakowsky [continuing]. Really mean for patients?
    Dr. Lembke. Well, what that means is that you want to get 
addiction treatment for patients who are struggling with the 
disease of addiction, and you can't get insurance companies to 
pay for it, which means that patients don't access the 
treatment. All you are left with is non--you know, 
interventions outside of the infrastructure of medical 
institutions, which is primarily just the 12-step movements. So 
it is a huge problem.
    Ms. Schakowsky. And so in your opinion, and anybody else 
can weigh-in on this too, would increased coverage of MATs help 
more individuals to remain in recovery?
    Dr. Lembke. Well, what happens now is that--what I see with 
private insurers is that they say they cover MATs, but then, 
basically, they have all kinds of loopholes whereby they can 
deny that coverage, and they just make it so incredibly 
bureaucratically cumbersome in real time, you know, in the 
trenches, that you end up throwing up your hands. And once you 
start somebody on buprenorphine, you don't want to just 
suddenly not have it available to them, but that happens 
frequently because all of a sudden, you have been denied 
coverage. It is insane.
    Ms. Schakowsky. Anybody else want to comment on that?
    Dr. Seppala. Yes, I could speak to it.
    Ms. Schakowsky. Yes, Dr. Seppala.
    Dr. Seppala. We have had to increase our own infrastructure 
just to have enough people involved to get these medications 
approved.
    Ms. Schakowsky. You are talking about people who spend time 
on the phone and----
    Dr. Seppala. Yes. Yes.
    Ms. Schakowsky. OK.
    Dr. Seppala. So trying to limit our doctors' involvement 
and have other people do that, usually nurses, but it really 
has required adding FTEs to what we do. So increasing our 
expenses just to get these medications approved by insurance 
companies.
    Ms. Schakowsky. And eventually you do get them approved 
usually?
    Dr. Seppala. I would say usually is a good description. Not 
always.
    Ms. Schakowsky. Yes. OK.
    Dr. Harris. And I also would like to add that it is 
increasing coverage for MAT, but it is also increasing coverage 
for the other interventions; the behavioral interventions, the 
therapies, cognitive behavioral therapies, the other therapies 
that we know compliment MAT and work well.
    Ms. Schakowsky. And those are hard to----
    Dr. Harris. It is very difficult to----
    Ms. Schakowsky [continuing]. Get approved?
    Dr. Harris [continuing]. Get coverage for that, yes.
    Ms. Schakowsky. Thank you. OK, I don't know, can Dr.----
    Dr. Bisaga. Can I--yes, on the other hand, another trend is 
that insurance companies know that this saves them money. 
Evidence-based treatment saves money. So we also see a trend of 
them declining to pay for the programs that do not offer 
evidence-based treatment; psychotherapy and the medication and 
on the 12-step. So that is another good trend. So hopefully we, 
you know, we can use the data to inform how we should actually 
invest in the public healthcare.
    Ms. Schakowsky. Thank you so much. Thanks, Mr. Chairman.
    Mr. Murphy. Well, I want to follow up on what she is 
saying. It is very important, especially in light of the mental 
health parity. So we want to make sure that evidence-based care 
is there. Medication-assisted treatment is there as part of a 
protocol, psychosocial therapy is part of a protocol, using the 
proper things. Just talk therapy in a general concept isn't 
going to work, it has to be very focused with someone who 
understands addiction. And part of our challenge here is, we 
had previous testimony from some places just talking about pill 
mills where doctors are just cranking out lots of medication, 
and since 90 percent of people we found weren't in any kind of 
treatment, and of those getting treatment, only 10 percent of 
that were getting the evidence-based treatment. It sounds like 
what you are saying the insurance companies are kind of 
throwing the baby out with the bathwater here, responding to 
Ms. Schakowsky's questions, making it very difficult to get 
proper treatment. And since most people aren't getting 
treatment anyway, shouldn't they be focusing on something else? 
Dr. DuPont?
    Dr. DuPont. A point about that--that the evidence of what--
what is the evidence we are talking about, and the evidence for 
evidence-based is what happens to the person while they are 
taking the medicine. It is not what happens to them later. 
Where do they go? And what I am encouraging is to have 
evidence-based assessment of what the consequences are--what 
the long-term outcome is of all of these treatments. Which 
treatments are getting people into stable recovery, which are 
not. And that is not what we are doing now. Our evidence is 
what happens while they are there, in the face of the fact that 
you have very rapid cycling through these programs. If we are 
talking about dealing with an epidemic, we have to deal with 
those people as individuals for their lifetimes, for long 
periods of time. That is why I say 5 years. So evidence-based 
of while they are in the treatment is good, but it is not what 
we really want. Is it evidence of getting them into stable 
recovery or not----
    Mr. Murphy. Thank----
    Dr. DuPont [continuing]. That is the question that has to 
be asked.
    Mr. Murphy. Thank you.
    Ms. DeGette, 5 minutes.
    Ms. DeGette. Thank you very much.
    Dr. Lembke, I am listening with interest to this 
discussion, and others might have also input on this, but why 
is it so difficult to get insurance companies and others to pay 
for these appropriate treatments?
    Dr. Lembke. My belief is that essentially insurance 
companies do not want people on their panel who have chronic 
lifetime diseases that will need chronic lifetime care, and 
they essentially view the addicted population wrongly as folks 
who cannot get better and will always need lots of medical 
care. And it is really an untrue bias that insurance companies 
have that mirrors a bias that society has, because the truth is 
when you get addicted persons into quality addiction treatment, 
they have about 50 percent response recovery rates, which is on 
par with recovery rates for depression and many other chronic 
illnesses----
    Ms. DeGette. So----
    Dr. Lembke [continuing]. With a behavioral component.
    Ms. DeGette. So you think that they don't want to--they are 
reluctant to get--pay for a treatment plan if they think that 
it could be a chronic long-term plan?
    Dr. Lembke. Yes, that those people are going to be----
    Ms. DeGette. Yes.
    Dr. Lembke [continuing]. Costly for them. They don't----
    Ms. DeGette. Right. And----
    Dr. Lembke. They don't want to----
    Ms. DeGette. And you think one of the solutions might be 
putting more patients on those boards?
    Dr. Lembke. Patients on----
    Ms. DeGette. People who have dealt with recovery and so on, 
is that what I am hearing you saying?
    Dr. Lembke. On what boards?
    Ms. DeGette. On the insurance review boards.
    Dr. Lembke. You know, it is a weird group thing that 
happens even when you have physicians who you have to talk to 
who are representing insurance companies, their mandate is to 
withhold care. Their mandate is to pay for as little as humanly 
possible. I mean I can tell you horror stories about hour-long 
conversations I have had with physicians representing insurance 
companies who then denied care in cases where care was----
    Ms. DeGette. So----
    Dr. Lembke [continuing]. Obviously needed.
    Ms. DeGette. So, Dr. Bisaga, I want to follow up with that 
because in your testimony, you said that very few of the 
patients with opioid addiction receive treatments that have 
been proven to be effective, and you said the treatment most of 
them were receiving is outdated and mostly ineffective. What 
kind of treatment is that that people are receiving that is 
just not working?
    Dr. Bisaga. Right, so we just had a wonderful example from 
Dr. Seppala talking about kind of the best possible treatment 
that marriages very efficiently 12-step with the medications. 
This is really, really exception. This is 1 of the 1 percent. 
Majority of people, the treatment consists of going to the 
hospital, getting detoxified, and then trying to be encouraged 
to go to the 12-step meetings without being told even that 
there are evidence-based medications.
    Ms. DeGette. So what it is, it is kind of a truncated 
treatment. It is like we are----
    Ms. Bisaga. Again----
    Ms. DeGette [continuing]. We are going to give you some--
maybe we are going to give you some medication, we are going to 
make--we are going to tell you to go to this treatment, then 
you are on your own.
    Ms. Bisaga. Right. So we only going to detox you, and we 
expect you--that you going to stay abstinent. There is no 
information about the evidence-based medications. After 
detoxification, opiate blocker could be a way to maintain----
    Ms. DeGette. OK. So there is not--there is not even 
medication involved in most of these.
    Ms. Bisaga. No. Many inpatient detoxifications do not put 
people on medication. It----
    Ms. DeGette. They just detox them----
    Ms. Bisaga. Yes.
    Ms. DeGette [continuing]. And then they----
    Ms. Bisaga. Detox them and sell them to 12-step groups.
    Ms. DeGette. OK.
    Ms. Bisaga. It is changing, but slowly.
    Ms. DeGette. And do all of the rest of you agree with that, 
that that is what is going on for the most part? Yes? OK.
    Now, Dr. Westreich, you said in your testimony, patients 
and their families need to know that detoxification treatment 
and drug-free counseling are associated with a very high risk 
of relapse. So it is sort of the same question that I was 
asking Dr. Bisaga, do you think that patients enrolling in 
programs that employ this approach are being given adequate 
information to make informed decisions about their treatment?
    Dr. Westreich. Well, I think that is exactly the question. 
At the middle and end of that treatment episode, they should be 
given information about their particular case and what their 
likelihood for relapse is, and what possible treatments are, 
including medications, including abstinence models, and be able 
to make an informed decision based on having those treatments 
available to them. And my concern is when they are not 
available, the person cannot make an informed decision.
    Ms. DeGette. Right. If you never have MAT offered as an 
alternative, you can't have a complete program.
    Ms. Westreich. Exactly.
    Ms. DeGette. And this is not just your idea or the other 
esteemed members of this panel, this is like scientifically 
proven, right?
    Dr. Westreich. Yes.
    Ms. DeGette. Yes.
    Dr. Lembke. Can I just add one thing?
    Ms. DeGette. Please.
    Dr. Lembke. You know, MAT works for some people, it doesn't 
work for everybody----
    Ms. DeGette. Right.
    Dr. Lembke [continuing]. And what some people who are in 
the acute crisis of the disease of addiction need is to be put 
into a hospital so they can detox, and hopefully then get 
routed to some kind of behavioral or residential treatment. And 
that is also very hard to get insurance companies to pay for.
    Ms. DeGette. Right, and if you can find a program to put 
them in.
    Dr. Lembke. Even to put them in the hospital----
    Ms. DeGette. Exactly.
    Dr. Lembke [continuing]. I mean, even to put them in the 
hospital for 3 or 4 days is very hard.
    Ms. DeGette. And, you know, let me just say, Mr. Chairman, 
I really appreciate this hearing because this is exactly what I 
have been trying to say is, it is not a one-size-fits-all 
solution for these patients, there are different types of 
solutions, but if you take out one of the programs that really 
works, like MAT, or the MAT plus the intensive long-term 
counseling, not only are you going to have a failure rate, but 
you are also going to have deaths. So thank you.
    Mr. Murphy. And even that is difficult for them to get.
    Dr. Burgess, recognized for 5 minutes.
    Mr. Burgess. Thank you, Mr. Chairman. And I do have a 
number of questions for Dr. Harris. Thank you for being here 
today. I may end up submitting those to you in writing and ask 
for a written response because I do want to use part of the 
time that I have available to get on my soapbox. That is what 
we do here.
    This is not quite the appropriate hearing, but this 
subcommittee does have jurisdiction over the Food and Drug 
Administration, and several times we have had the Food and Drug 
Administration in, I have asked the question why we cannot have 
the availability of naloxone or Narcan as an over-the-counter 
purchase. Why Federal law prohibits dispensing without a 
prescription, but why? No one is going to abuse Narcan. Narcan 
can be a lifesaving measure. Sure, I want first responders, 
police departments, EMTs, I want them to have it available in 
their armament when they arrive on the scene of a person who is 
unconscious. Are there--I don't think we will be inducing 
anyone to misbehave by having a rescue method at their 
disposal.
    So, Mr. Chairman, I just wanted to get that out of the way. 
I do think the Food and Drug Administration needs to work on 
this. I think this is one of the things that--I mean you 
referenced in your opening statement the tragedies that occur 
happen in my suburban area as well. The tragedies that occur 
when we lose a young person through what presumably is an 
unintentional opiate overdose.
    And then the other thing that I just feel obligated to talk 
about, I mean I was in practice for a number of years. Covered 
for other doctors, as we all do, and I know there were times 
that I was burned by a patient who was exhibiting drug-seeking 
behavior and I didn't immediately recognize it. I tried to 
guard against that. In fact, the latter years that I was in 
practice, I would not fill a prescription of a patient I did 
not know over the phone, I would go to the office and look up 
their chart. If I couldn't find their chart, yes, that might be 
on us because we didn't have electronic records, we had paper 
charts, I would offer to meet that patient in the emergency 
room and evaluate their signs and symptoms, and if appropriate, 
prescribe a medication. Suffice it to say, most of the time 
that did not occur and the patient was not willing to come in 
and spend the time required.
    But look, we have prescription drug monitoring programs. 
And I will tell you one time just sticks out in my mind how 
frustrated I was. Called in a prescription for a patient with a 
very plausible story, and the pharmacist said, you know, you 
are about the fifteenth doc that has called in medicine for 
that patient this month. And I said, what, that is crazy. Well, 
cancel the prescription. He said, you have already called it 
in, I will fill it for her when she shows up, but I just 
thought you ought to know. And I forget the number he gave me, 
but it was an astounding number of Tylenol III that this 
patient had received during the month. And forget the codeine 
part of the prescription; this was a multiple times lethal dose 
of acetaminophen that, if somebody had actually ingested it, 
their liver was long gone and someone would be paying for a 
liver transplant. We have prescription drug monitoring 
programs. We have one that was passed by this committee, called 
NASPER, and President Bush signed it into law in 2005. There is 
a competing program that was done by the appropriators. That is 
not your problem, that is our problem. But, Mr. Chairman, it 
just underscores how we need to fix that. And now, we ask the 
American people with the Stimulus Bill to fund this large 
electronic health records, and do we have the interoperability 
so a doc in practice would know what that patient is taking? We 
don't really have the availability of getting that because of 
HIPAA, there are some privacy concerns. Somehow we need to 
bridge that gap, and I really would welcome anyone's comments 
on the panel about the prescription drug monitoring aspect.
    Dr. Westreich. I would like to comment----
    Mr. Burgess. Yes, Doctor.
    Dr. Westreich [continuing]. On both. First, I agree 1,000 
percent about Narcan, having that available not only to first 
responders but to families of people who have members who use 
opioids. I agree with you, and I don't see any reason why that 
can't happen.
    Regarding the prescription monitoring programs, we have one 
in New York State where I practice, where I am obligated to 
look at it each time I prescribe an opioid medication. There is 
one in New Jersey which covers Connecticut and Delaware, but 
there is no national one. So someone can be getting an opioid 
medication in the State next door and I would have no idea from 
the pharmacy monitoring program. We need to have a fully 
national program, and it would be enormously helpful for 
treating our patients.
    Mr. Burgess. Our other problem is we have to--yes, Dr. 
Seppala? I am sorry.
    Dr. Seppala. I would like to support both of your 
recommendations, Congressman. We should have over-the-counter 
naloxone. It is a very innocuous drug, you know that, and there 
are not many side effects or problems you could cause with it. 
It does one thing; it blocks opioid receptors in a very safe 
manner.
    And as far as the prescription drug monitoring programs, 
when they are not mandatory, as was described earlier, only 
about 33 percent of the docs use it, so there is not adequate 
information on them. We need it to be mandatory and across 
State lines. So I agree with both.
    Mr. Burgess. Yes, Dr. Harris?
    Dr. Harris. Yes, PDMPs are a valuable tool. They have 
valuable information, important information for doctors who are 
prescribing, however, they have to be easy to use, available at 
the point of care. Totally agree with interoperability.
    I do want to say that we have some data, we look across the 
States, and where they are readily available at the point of 
care and have real-time information, doctors are using them, 
but where they are more burdensome and don't have real-time 
information, doctors are not using them as much. And so I think 
the AMA is actually--I chair a task force looking at this 
issue, and one of the things we might come up with is perhaps 
what should a model PDMP look like, to give guidance on that so 
that doctors increase their use of PDMPs.
    Mr. Burgess. Thank you.
    Mr. Chairman, I will yield back.
    Mr. Murphy. Yes, just as a follow-up. So what you are 
describing here is just to even know when you are prescribing--
you know if a patient has already been prescribed opioids by 
their physician, to be able to follow that up. And then in 
addition to that--but you are also treating someone with an 
addiction disorder. That is the 42 C.F.R. Part 2 issue.
    Dr. Lembke, can you comment on that about how we need to 
make modifications to that? I am thinking that our former 
colleague, Patrick Kennedy, is always on me saying we have to 
fix this problem too, that someone has--getting addiction 
treatment, they are not even going doctor shopping, they are 
actually trying to get help, and they go see another doctor, 
the doctor doesn't know they are getting addiction treatment 
and he says, here, take this Percocet, take this. Can you 
comment on that, Dr. Lembke?
    Dr. Lembke. Yes, so the phenomenon we essentially have 
today is that on one side of the aisle in a medical institution 
you have people prescribing Vicodin, on the other side of the 
aisle you have people trying to get them off of it, and each 
other doesn't know what the other is doing because, according 
to 42 C.F.R., we cannot--it is a higher burden of privacy than 
even HIPAA, if someone is getting substance use treatment, we 
cannot communicate without their expressed consent to another 
provider that they are getting that treatment.
    This Code of Federal Regulations was implemented more than 
2 decades ago with good reason. What was happening was that 
police were going into methadone maintenance clinics and 
essentially arresting people who were trying to get treatment 
for their addiction. And so it was a higher burden on privacy 
so that people wouldn't resist going into treatment because 
they were afraid of being exposed around their addiction. But 
in this day and age of electronic medical records, and this day 
and age of prescription drug misuse, most importantly, as well 
as just the fact that we are trying to advocate for addiction 
being a disease, and we can't advocate for addiction being a 
disease if we treat it differently from other diseases. So I 
believe we have to amend 42 C.F.R. so that doctors can 
communicate openly about which patients are possibly misusing 
the drugs that they are prescribing to other providers caring 
for those patients.
    Mr. Murphy. Other people agree with that?
    OK, Mr. Tonko, you are recognized for 5 minutes.
    Mr. Tonko. Thank you, Mr. Chair.
    All of us on this dais are seeing the toll that addiction 
can have on our communities. However, with that in mind, 
insufficient data are available in the field of opioid 
addiction treatment. I would like to better understand from our 
panelists just how we should move forward with investments in 
research. How should those efforts be utilized to improve 
recovery outcomes?
    Dr. DuPont, you have been treating opioid addiction for a 
long time. How would you advise us in terms of research 
dollars--we obviously need to do more in research, I would hope 
that would be an agreement across the board here, but how 
should those dollars be invested, in what ways are they most 
beneficial?
    Dr. DuPont. Evaluations of outcomes over a longer period of 
time. But I want to bring up something that I don't think has 
been clear here, and that is no matter what happens with 
prescription drugs, there is a robust heroin market and it is 
getting bigger all the time, and I think it will be a huge 
mistake for us to think that the only problem we have is 
prescription drugs. That is contributing to it, that has kicked 
it off, but now it has taken off in an entirely different 
direction and it is huge, and I think we underestimate the 
power of heroin distribution in the country that produce high 
quality products at low cost, and that is just going to get 
worse. So I think that is something to keep in mind.
    The other thing is----
    Mr. Tonko. But that supply and demand equation is something 
we hear about all the time. I hear about it all the time in the 
district. People are very concerned.
    Dr. DuPont. Well, it is a very, very serious problem, and 
it drives me nuts that people who want to solve the drug 
problem by legalizing drugs. I say let's start with heroin. We 
are going to solve that problem by legalizing it? Give me a 
break. But it is a very serious problem for us to deal with.
    But the other point is, most people who have this problem 
do not see that they have a problem. They do not want 
treatment. When they go to treatment, they drop out of 
treatment. To get good long-term outcomes the answer is not 
just in the treatment. You can improve treatment and improve 
treatment and improve treatment, and you are still going to 
have tremendous frustrations getting people in, and keeping 
them in and keeping them clean when they leave. And that is why 
I studied the physicians health programs, because what those 
programs do is monitor the people for 5 years. And the 
physicians don't have a choice of getting out once they are 
diagnosed, and it is interesting how positive they are about 
that. I think one of the things this committee could do is look 
at the environment in which the choice is made to use and not 
to use, and think about what can be done to change that 
equation.
    One area of tremendous potential is the criminal justice 
system, where there is the kind of leverage that you have. You 
have 5 million people on probation and parole in this country, 
many of whom are opiate dependent, but I think also for 
families to understand that they have to be concerned about 
somebody who has an opiate problem, and not--and essentially 
manage that environment for that person, because that person's 
judgment is changed by the addiction and they are helpless on 
their own without somebody intervening. So I would suggest 2 
things. One is look long-term, and the other is think about the 
environment in which that is going on, and think about ways of 
using the environment to promote recovery.
    Mr. Tonko. And to our other panelists, are there ways that 
research can be connected into positive treatment outcomes?
    Dr. Seppala. Absolutely. It should be one of the focuses of 
most research to look at positive treatment outcomes, and 
actually negative treatment outcomes, to define both for the 
rest of the field so we know what we are doing, and we can 
individualize care in a much better way. Right now, there is no 
research that shows who should be on buprenorphine versus who 
should be on Vivitrol. It has not been defined. Our field is 
limited in regard to the type of research to make those 
decisions. We need a great deal more research in this field.
    Mr. Tonko. Is there anything that has been planted as a 
seed that needs to be grown to a bigger program of research, or 
is it just being avoided in general?
    Dr. Seppala. I think research dollars are so limited across 
medicine right now that it is really hard to get----
    Mr. Tonko. Well, there is a theme around here at times to 
cut research, which I oppose. I think it is the wrong path, 
but----
    Dr. Seppala. We have a huge system, we are in 16 States, 
and we don't even have the infrastructure to gain grants from 
NIH. We can't do that, we have to partner with people to get 
research dollars. The research we are doing on this program I 
described is self-funded. We can't get the money we need to do 
the research in our setting.
    Mr. Tonko. Anyone else on the panel? Yes, Doctor.
    Dr. Bisaga. Well, I mean, you know, the most of the rest of 
the medicine is moving towards personalized medicine or 
precision medicine, but we are trying to find out which 
treatments work best for which patients so we can avoid wasting 
time giving ineffective treatments. And this is very relevant 
to this hearing because we have four methods of treatment; 
three medication and maybe some people will even respond to no-
medication treatment. And we have a lot of people affected by 
the illness. So investing in pursuing, again, research, which 
patients should be treated with which medications, which can be 
done probably, would be the very smart way to use the research 
dollars to address this, you know, huge problem.
    Mr. Tonko. I, with that, yield back.
    Mr. Murphy. Thank you. Excellent questions.
    Ms. Brooks, 5 minutes.
    Mrs. Brooks. Thank you, Mr. Chairman, and thank you so much 
for holding this critical hearing.
    Last year in Indianapolis, an area that I represent, and to 
the north, we saw massive spikes, and I heard from our public 
safety officials, and I a former United States Attorney, about 
the increased use of heroin in our communities. I met with law 
enforcement officials first before meeting with treatment 
providers to see what they were seeing, and one of the greatest 
frustrations some of the law enforcement officials in 
Indianapolis had, who have now been trained in the use of 
Narcan, it is a pilot project being used in the city, they 
would save someone, and about 2 weeks later save them again. 
Same person who they have saved their life, they are now 
getting saved once again by even the same officer. And what 
they were so frustrated about is, where are the treatment 
providers. You know, we are saving them, you know, they are 
taken to the hospital, where is the system, what are we doing.
    Then when I met with treatment providers, obviously, as we 
have learned, I mean it is very, very difficult, A, to get 
people to stay in treatment, to realize they need the 
treatment. Drug courts sometimes work, and not enough 
communities have drug courts, although I have recently heard 
that drug courts--some drug courts are not allowing medication-
assisted treatment. I am curious what your thoughts are about 
that, because we fund drug courts. Much of their funding comes 
from Federal grants. And so I think that is something that we 
ought to realize that when these patients are going in to the 
drug courts, which can save their lives, there is no question 
about it, would like your comments on that. And then finally, I 
just would ask all of you, because physicians, whether they are 
in the ER, whether they are part of treatment providers, or 
whether they are treating them for something else, what more 
should we be doing to educate our physicians, because I have 
also prosecuted physicians who became pill mills for 
communities, this was back in the Oxycontin days, but what do 
we need to do to better educate physicians and psychiatrists 
about how to treat addictions, because we are not there, we are 
not even close to being there. And I applaud all of you for 
your work. And I guess I would start with the drug treatment 
courts that we actually may have some leverage over. I don't 
know who would like to comment about drug treatment courts.
    Dr. Bisaga. If I may. You know, I have a lot to say on the 
issue of these topics, but this is very important topic because 
a lot of people who are under criminal justice system custody 
really are there because they have a disease that affects their 
functioning and may cause them to do criminal things, and the 
way to help them get out of the custody is to treat their 
medical illness, which is an addiction. However, the drug 
courts and the judges still, I think, tend to think in the old 
days, thinking that the way to treat them is to send them to 
the medication-free treatment, not medication-assisted 
treatment. So we are working with the Bureau of Prisons, and 
hopefully you guys can help with that tool, to encourage them 
to use evidence-based treatment when they are making decisions 
about the medical treatments. It can be done in combination 
with the decision about the, you know, criminal justice with 
ability. So----
    Mrs. Brooks. Because, you are right, our prisons, which we 
also fund, obviously, as people are coming out of prison, 
probably one of the top reasons they recidivate and are back 
within a short period of time is they didn't have their 
addiction dealt with, and they are--anyone else like to 
comment----
    Dr. Westreich. Yes, as----
    Mrs. Brooks [continuing]. Or all of----
    Dr. Westreich. As to drug courts, I mean I would say on 
both of your questions, education is the key. I think drug 
courts are great. I think judges and lawmakers need to be 
educated about addiction itself and not practice medicine. In 
the same way, we clinicians need to be educated about law and 
about the necessity for a holding structure of people who are 
addicted. So I think drug courts work well when everyone is 
educated about what they are doing, about therapeutic 
jurisprudence, which is what that is.
    Secondly, as far as educating doctors, I agree 100 percent. 
I think we need to have much better efforts both through the 
auspices of groups like mine, and organized medicine in 
general, to educate not only psychiatrists but primary care 
doctors and all physicians about prescribing practices, and 
then about recognizing and treating addiction in an evidence-
based manner. So education in both spheres, I think.
    Dr. Lembke. We give a lot of lip service to addiction being 
a chronic medical illness, but we don't actually treat it like 
one, either in the medical system or in the criminal justice 
system. I cannot imagine a judge working with someone in the 
criminal justice system saying you have to go off your diabetes 
or your hypertension meds, otherwise you can't be in this court 
system. We wouldn't accept that, and yet we accept them saying 
to these individuals you can't be on Suboxone.
    So obviously, we don't regard it as an illness. Even within 
the medical system, doctors do not treat it like a medical 
illness. So we need a huge frame shift. And I think education 
is really important, but unless, again, you incentivize doctors 
and judges, and whoever it is, to really treat it like an 
illness and create the infrastructure to treat it like an 
illness, you are not going to make any headway.
    Mrs. Brooks. And while my time is up, Mr. Chairman, I 
believe Dr. Seppala would like to address that question as 
well, if that is oK. Thank you.
    Dr. Seppala. I would. We have had a couple of leaders of 
the drug court system come and look at our program, and they 
have held a fairly conservative stance in regard to the use of 
Suboxone and other maintenance medications for opioid 
dependence over time, but I think they are shifting. So I 
believe that you could play a huge role in pushing them along 
in this direction. They need to go there.
    Mrs. Brooks. And their education.
    Dr. DuPont. Could I just make one quick comment about this? 
In the physicians health programs, about \1/3\ of the 
physicians in those programs are opiate addicts, about \1/2\ 
are alcoholics, and the rest are other drugs. We looked at what 
happened to the opiate addicts' physicians, none of them were 
given Suboxone or methadone, and they did as well as the 
alcoholics in their long-term outcomes. They did very, very 
well without medication. Now, that is a specialized population, 
I don't want to generalize it, but I just want to get that 
clear.
    I would suggest in the drug courts that the committee 
encourage the drug courts to actually look at the question, 
like they are doing in Hazelden, and see for themselves, do 
they get better results when they offer that as an option. I 
think that is a researchable question. I think it could go 
either way. I don't know what would happen, but I think that 
would be the way to talk about it with them, and I think they 
would be receptive to that.
    Mrs. Brooks. I want to thank you, Mr. Chairman, for that. 
And I think with respect to educating judges and lawyers, while 
you are focused on physician addicts, there are plenty of 
judges and lawyers who also could share their knowledge and 
experience, and maybe help better educate our judges and 
lawyers.
    I yield back.
    Mr. Murphy. Thank you.
    I now recognize Mr. Kennedy for 5 minutes.
    Mr. Kennedy. Thank you, Mr. Chairman. I want to thank the 
chairman and the ranking member. I want to also thank an 
extraordinary group of panelists for your dedication to this 
issue, which is really--it is a preeminent group that we have 
here. So thank you for your testimony today. It has been a big 
help, I think, as we try to think through these issues.
    And, Chairman, I also want to thank your kind comments 
about my cousin, Patrick, as well. This has obviously been an 
issue that has been very close to his professional life's work, 
and I appreciate your recognition of those efforts.
    A number of you have talked about incentives over the 
course of the testimony today. And, Dr. DuPont, you also 
mentioned the impact of heroin and the heroin trade. I, like my 
colleague, Ms. Brooks, was a prosecutor--I was a State 
prosecutor. I ended up prosecuting an awful lot of property 
crimes; breaking and entering cases, that were more--it was 
kids, 18, 20, 22 years old, that were breaking into 15 cars in 
a night to try to feed an Oxycontin addiction. Massachusetts 
has been struggling with this for years now. I met recently 
with the DEA and, you know, rough numbers, but they describe 
the drug trade with Mexico alone to be in the order of $30 
billion a year. And a big percentage of that is heroin. So 
until we kind of wrap our minds around the fact that, as the 
street market for Oxycontin is 80--or essentially, a buck a 
milligram, so $80 a pill, but you can get heroin for $3 or $4 a 
bag, there is a very strong economic incentive to push you into 
heroin. And I think I have said this before at these hearings, 
meeting with local law enforcement, meeting with Federal law 
enforcement back home, a widespread recognition, we will not 
arrest our way out of this problem. So the question becomes, if 
it is a demand-based epidemic, because people are addicted and 
that is fueling either because of overprescription, because of 
easy access, and then a migration towards heroin, how do we 
make sure that we don't even get there in the first place?
    So, one, I wanted to get some thoughts from you, Dr. DuPont 
and Dr. Lembke, as to what we can be doing to make sure that 
your efforts here hopefully one day aren't necessary, but then 
two, we have touched on this a little bit, in my study of 
this--people will follow incentives, and the Federal Government 
has systematically underinvested in substance abuse treatment 
and in mental health now for decades. I hear from our 
hospitals, our doctors, our patient groups, everybody, our 
judges, our court system, there are not beds for people to get 
treatment. So if we start reimbursing for--if you start to put 
the economic incentives in for doctors to get compensated 
adequately for their time for there to be actually treatment 
facilities, you will see more beds, you will see more treatment 
facilities, you will see more wraparound services. So I was 
hoping to get both of you to comment on that as well, and 
what--I guess bifurcated question to start, what should we be 
doing to--hopefully to make sure we actually one day don't need 
all of these services you are talking about, and in the 
meantime, what incentives--where should we be really focused on 
these incentives to build up and flush out so that people can 
get the continuum of care that they need?
    Dr. DuPont. Well, I think one thing to focus on is the drug 
problem is not just about heroin or opiates; we have a very 
serious drug problem across a very broad spectrum to deal with. 
But I also want to just say it has been my privilege to work 
with Patrick often, and he is a genuine hero of our field and a 
hero to me. An extraordinary guy who is making a tremendous 
contribution.
    And I want to go back to those young men you were arresting 
and prosecuting. One of my preoccupations is the use of the 
criminal justice system in what was described as therapeutic 
jurisprudence. When that person is arrested, there is an 
opportunity to change his life direction in a very positive 
way. And one of the most striking programs about this is called 
Hope Probation from Hawaii, which uses the leverage of the 
criminal justice system to promote recovery. I visited out 
there, and let me tell you something, the treatment programs 
love the people that they get from Hope probation because they 
do stay, they do pay attention, they do get better, because 
they are required to be drug-tested for their probation. And so 
it makes treatment work like that. And I think that there is a 
real opportunity to use that as an engine for recovery that 
should not be overlooked when a person is out of control. But I 
don't think we are going to treat our way out of this either. 
We have to deal in an integrated way with a very complex 
problem, and the problem is the drugs really work. People do 
not understand the potential. They think somehow there is--some 
small percentage of the population is vulnerable to drug 
addiction. That is not correct. It is a human phenomenon, it is 
a mammalian phenomenon. And when there is access to these 
drugs, an awful lot of people are going to use them, and a lot 
of the people who use them are going to be stuck with that 
problem for the rest of their lives. This is a very big 
problem, of which this is a very important part.
    Mr. Kennedy. I am already over time, but if I could ask you 
to just answer as briefly as you can.
    Dr. Lembke. Just briefly. I really appreciate your emphasis 
on incentives, particularly in changing doctors' behavior and 
creating the infrastructure to treat the illness. Even if you 
don't believe addiction is a chronic illness, we need to 
pretend like it is because, from a practical perspective, if we 
don't, we will just make people sicker, we won't make them 
well.
    And then what is really driving the recent heroin increase 
is young people, so I absolutely agree that we need to put our 
resources toward youth, and not just for the short term, but 
they need to learn how to live differently in the world and 
whatever that takes, changing the structure of their lives and 
their friendship groups, giving them jobs, socializing them in 
a better way to adapt to contemporary culture is, I think, you 
know, where it is, not just short-term and long-term.
    Mr. Kennedy. Thank you.
    Thank you, Mr. Chairman.
    Mr. Murphy. And, Ms. Clarke, you are recognized for 5 
minutes.
    Ms. Clarke. Thank you, Mr. Chairman. And I want to thank 
all of our witnesses for giving this committee the benefit of 
your expertise and experience today.
    I would like to focus my questions on the prevention side 
of the equation. I know we have discussed the array of access 
points to heroin and opiates, and I would like to focus us back 
to the universe of prescribed opiates.
    According to the National Institutes on Drug Abuse, the 
number of prescriptions for opiates in the United States 
escalated from 76 million in 1991, to about 207 million in 
2013. Between 2000 and 2010, there was a fourfold increase in 
the use of prescription opiates for the treatment of pain. The 
uptake in prescriptions for opiates has been accompanied by a 
corresponding increase in the number of opiate-related overdose 
deaths.
    So let me start with Dr. Seppala. My question to you is, 
are opiates being overprescribed, and I want to get to the why 
if that is the case?
    Dr. Seppala. Yes, they are being overprescribed, and they 
are being used for purposes that they are not necessarily 
proven to be effective for, and particularly when it comes to 
chronic pain.
    Opioids are the best, most powerful painkillers on the 
planet. They are necessary for the practice of medicine and for 
relief of suffering, but primarily, in an acute pain situation. 
Chronic pain studies are not long-term and don't show over the 
long-term the effective relief of chronic pain. Opioids just 
don't work that well, and yet they are being prescribed readily 
for that, so people are taking them for months and years.
    Ms. Clarke. So is there a standard of care as to when it is 
appropriate to prescribe opiates for the management of pain?
    Dr. Seppala. Yes, there are standards of care defined for 
the prescription of opioids for pain, for acute pain and for 
chronic pain, and there has been a shift in how that is viewed, 
and the standards have shifted over the last 10 years, first to 
increase the prescribing of opioids for chronic pain, and now 
to decrease and go back to a more conservative approach. So it 
is being understood in medicine but, you know, I am reading the 
literature right out of the pain folks who understand this, and 
the primary care docs don't necessarily follow suit for years--
--
    Ms. Clarke. Um-hum.
    Dr. Seppala [continuing]. They still have to kind of catch 
up, so we do need to educate our physician population.
    Ms. Clarke. Dr. Lembke, I would like to get your thoughts 
on that as well.
    Dr. Lembke. Well, there is a long story to why we 
overprescribe prescription opioids, which we do, and basically, 
it started in the 1980s when there was this recognition that we 
were not doing enough to treat pain. It also coincided with the 
hospice movement. And there was a big push to use opioids more 
liberally for the treatment of pain, so doctors did that. What 
happened was that the evidence that showed the use of opioids 
was indicated for people who were dying was then turned over to 
the use of opioids in those who have chronic pain conditions. 
And Purdue Pharma and others aggressively marketed to doctors 
to use opioids for chronic pain, although there is no evidence 
to show that they are effective for chronic pain. And now 
reports are coming out that the risks far exceed any benefits 
that you might have for an individual patient. So now there has 
been a big seat change in that regard. Nonetheless, it is hard 
to get doctors to catch up with that seat change.
    Ms. Clarke. So are physicians not getting the appropriate 
level of training and education in pain management, and how to 
identify patients who may be at risk for addiction? And I don't 
know what that universe looks like. It sounds to me, just in 
hearing the dialogue, that just about everyone can be a 
candidate for addiction under that construct.
    Dr. Lembke. They are now getting that education, and there 
are standards. The problem is that a doctor gets paid twice as 
much for a 5-minute medication management visit as they do for 
1 hour talking to patients, so there is, again, no 
infrastructure to incentivize doctors to not prescribe pills. 
There is a lot of incentive for them to prescribe.
    Ms. Clarke. Dr. Harris, would the AMA support mandatory CME 
or responsible opioid prescribing practices in addiction tied 
to the DEA registration of controlled substances?
    Dr. Harris. So I think the mandatory is the issue, and I 
think the AMA would like to offer an alternative approach 
because mandatory CME just feels like sort of a one-size-fits-
all. You have many psychiatrists here on the panel, and the 
education that we may need might be different than the 
education of our primary care colleagues, and so certainly more 
education is the key. We are right now cataloging best 
practices. Each of the specialties are looking at how should 
they educate their own colleagues. And so really it is about 
the right education at the right level, for the right 
specialty. So education is key, but certainly not mandatory. 
Feels like that is a one-size-fits-all----
    Ms. Clarke. I am over time but, Dr. Lembke, do you agree, 
should we be mandating or do you think that it should be left 
to the field to make----
    Dr. Lembke. Yes, so I respectfully disagree with Dr. 
Harris. I think that when doctors get their DEA license to 
prescribe controlled and potentially addictive medications, 
they should mandatory be taught how to use a prescription drug 
monitoring system, that that just simply should be the standard 
of care, independent of their subspecialty.
    Ms. Clarke. Mr. Chairman, I thank you for your indulgence. 
I yield back.
    Mr. Murphy. Thank you. This has been quite an enlightening 
panel. I have been writing down some of your recommendations. I 
have a number of things here. Change the 42 C.F.R. program to 
bring us up to 2015 standards of integrating physical and 
behavioral medicine so that we can know who is getting 
addiction treatments, and help the practices. Improve the intra 
and interstate communication between pharmacies and physicians 
so they can distinguish between patients who truly need a 
medication, versus those who are involved with addiction 
shopping. Better define recovery. Dr. DuPont, you had said not 
in terms of just today if they are off medication, but recovery 
as a longer term. And many of you have used the word chronic. 
And we need to be paying attention to longer-term data. We need 
more education to monitor physicians, and more education of 
monitoring for physicians so they understand prescription drug 
use here, and what treatment from pain is. We also have to make 
sure we do have insurance parity to truly deal with this 
treatment, something we have been dealing with on this 
committee for 6 or 7 years now. We need more providers who are 
trained and experienced with mental illness, severe mental 
illness, and addiction. More inpatient beds for treatment for 
detox, for in-depth treatments that meets the needs of the 
patients. And understanding that medication-assisted therapy 
and psychosocial therapy are not enough; we have to make sure 
that we have this spectrum, the pallet of treatments available 
to people to meet their needs.
    I think now as we look at that sobering number of 43,000 
overdose deaths, and 1 \1/2\ million on some of these 
medications as treatments, we have our marching orders. This is 
not something that is simple, but it is something that I think 
is doable. And the good news is this is the committee that can 
do it, so we will get our work together.
    Again, I want to thank this very distinguished panel. 
Remind members that they have a few days to get to us their--
what is it?
    Voice. Ten business days.
    Mr. Murphy. Ten business days to submit questions for the 
record. And ask all the witnesses if you would respond promptly 
to this. Again, thank you so very much. We have our work cut 
out for us.
    This committee is adjourned.
    [Whereupon, at 1:03 p.m., the subcommittee was adjourned.]
    [Material submitted for inclusion in the record follows:]
    
    
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