[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]
Printed for the use of the Committee on Energy and Commerce
energycommerce.house.gov
___________
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COMMITTEE ON ENERGY AND COMMERCE
FRED UPTON, Michigan
Chairman
JOE BARTON, Texas FRANK PALLONE, Jr., New Jersey
Chairman Emeritus Ranking Member
ED WHITFIELD, Kentucky BOBBY L. RUSH, Illinois
JOHN SHIMKUS, Illinois ANNA G. ESHOO, California
JOSEPH R. PITTS, Pennsylvania ELIOT L. ENGEL, New York
GREG WALDEN, Oregon GENE GREEN, Texas
TIM MURPHY, Pennsylvania DIANA DeGETTE, Colorado
MICHAEL C. BURGESS, Texas LOIS CAPPS, California
MARSHA BLACKBURN, Tennessee MICHAEL F. DOYLE, Pennsylvania
Vice Chairman JANICE D. SCHAKOWSKY, Illinois
STEVE SCALISE, Louisiana G.K. BUTTERFIELD, North Carolina
ROBERT E. LATTA, Ohio DORIS O. MATSUI, California
CATHY McMORRIS RODGERS, Washington KATHY CASTOR, Florida
GREGG HARPER, Mississippi JOHN P. SARBANES, Maryland
LEONARD LANCE, New Jersey JERRY McNERNEY, California
BRETT GUTHRIE, Kentucky PETER WELCH, Vermont
PETE OLSON, Texas BEN RAY LUJAN, New Mexico
DAVID B. McKINLEY, West Virginia PAUL TONKO, New York
MIKE POMPEO, Kansas JOHN A. YARMUTH, Kentucky
ADAM KINZINGER, Illinois YVETTE D. CLARKE, New York
H. MORGAN GRIFFITH, Virginia DAVID LOEBSACK, Iowa
GUS M. BILIRAKIS, Florida KURT SCHRADER, Oregon
BILL JOHNSON, Ohio JOSEPH P. KENNEDY, III,
BILLY LONG, Missouri Massachusetts
RENEE L. ELLMERS, North Carolina TONY CARDENAS, California
LARRY BUCSHON, Indiana
BILL FLORES, Texas
SUSAN W. BROOKS, Indiana
MARKWAYNE MULLIN, Oklahoma
RICHARD HUDSON, North Carolina
CHRIS COLLINS, New York
KEVIN CRAMER, North Dakota
____
Subcommittee on Oversight and Investigations
TIM MURPHY, Pennsylvania
Chairman
DAVID B. McKINLEY, West Virginia DIANA DeGETTE, Colorado
Vice Chairman Ranking Member
MICHAEL C. BURGESS, Texas JANICE D. SCHAKOWSKY, Illinois
MARSHA BLACKBURN, Tennessee KATHY CASTOR, Florida
H. MORGAN GRIFFITH, Virginia PAUL TONKO, New York
LARRY BUCSHON, Indiana JOHN A. YARMUTH, Kentucky
BILL FLORES, Texas YVETTE D. CLARKE, New York
SUSAN W. BROOKS, Indiana JOSEPH P. KENNEDY, III,
MARKWAYNE MULLIN, Oklahoma Massachusetts
RICHARD HUDSON, North Carolina GENE GREEN, Texas
CHRIS COLLINS, New York PETER WELCH, Vermont
KEVIN CRAMER, North Dakota FRANK PALLONE, Jr., New Jersey (ex
JOE BARTON, Texas officio)
FRED UPTON, Michigan (ex officio)
(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:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
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:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
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:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
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:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
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:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
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:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
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.]
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