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

        WHAT ARE THE STATE GOVERNMENTS DOING TO COMBAT THE OPIOID ABUSE
                                   EPIDEMIC?

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

                                    HEARING

                                   BEFORE THE

                  SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

                                     OF THE

                        COMMITTEE ON ENERGY AND COMMERCE
                            HOUSE OF REPRESENTATIVES

                        ONE HUNDRED FOURTEENTH CONGRESS

                                 FIRST SESSION

                                   __________

                                  MAY 21, 2015

                                   __________

                               Serial No. 114-46

    [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...........................................     3
    Hon. Diana DeGette, a Representative in Congress from the State
      of Colorado, opening statement.................................     4
    Hon. Frank Pallone, Jr., a Representative in Congress from the
      State of New Jersey, opening statement.........................     6
        Prepared statement...........................................     7

                                   Witnesses

    Jerome Adams, M.D., M.P.H., Commissioner, Indiana State
      Department of Health...........................................     9
        Prepared statement...........................................    12
        Answers to submitted questions...............................    91
    Monica Bharel, M.D., M.P.H., Commissioner, Massachusetts
      Department of Public Health....................................    20
        Prepared statement...........................................    23
        Answers to submitted questions...............................    96
    Larry Wolk, M.D., M.S.P.H., Executive Director and Chief Medical
      Officer, Colorado Department of Public Health and Environment..    34
        Prepared statement...........................................    36
        Answers to submitted questions...............................   105
    Mark Stringer, M.A., L.P.C., N.C.C., Director, Division of
      Behavioral Health, Department of Mental Health, Missouri.......    40
        Prepared statement...........................................    42
        Answers to submitted questions...............................   111

                               Submitted Material

    Subcommittee memorandum..........................................    71
    Letter of May 21, 2015, from Don Flattery to Mr. Murphy and Ms.
      DeGette, submitted by Ms. DeGette..............................    86

        WHAT ARE THE STATE GOVERNMENTS DOING TO COMBAT THE OPIOID ABUSE
                                   EPIDEMIC?

                                  ----------

                             THURSDAY, MAY 21, 2015

                      House of Representatives,
          Subcommittee on Oversight and Investigations,
                              Committee on Energy and Commerce,
                                                        Washington, DC.
        The subcommittee met, pursuant to call, at 10:19 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,
    Griffith, Bucshon, Flores, Brooks, Mullin, Hudson, Collins,
    Cramer, DeGette, Tonko, Clarke, Kennedy, Green, Welch, and
    Pallone (ex officio).
        Staff present: Will Batson, Legislative Clerk; Andy
    Duberstein, Deputy Press Secretary; Brittany Havens, Oversight
    Associate, Oversight and Investigations; Charles Ingebretson,
    Chief Counsel, Oversight and Investigations; Chris Santini,
    Policy Coordinator, Oversight and Investigations; Alan
    Slobodin, Deputy Chief Counsel, Oversight; Sam Spector,
    Counsel, Oversight; Christine Brennan, Democratic Press
    Secretary; Jeff Carroll, Democratic Staff Director; Christopher
    Knauer, Democratic Oversight Staff Director; Una Lee,
    Democratic Chief Oversight Counsel; Elizabeth Letter,
    Democratic Professional Staff Member; Adam Lowenstein,
    Democratic Policy Analyst; and Timothy Robinson, Democratic
    Chief Counsel.

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

        Mr. Murphy. Good morning. Today we convene the fourth in a
    series of hearings examining prescription drugs and heroin
    addiction, the growing nightmare of one of America's biggest
    public health crises.
        Since our opioid hearings earlier this month, approximately
    2,400 Americans have died from drug overdoses, and most of them
    because of opioid abuse. The size of this problem and the need
    for a new paradigm of treatment cannot be understated, and the
    process of developing legislative solutions has already
    started. Ranking Member DeGette and I have identified 15 areas
    in need of reform. One of those is 42 C.F.R. Part 2, which
    governs confidentiality protections for all substance use
    treatment records, both behavioral and physical, generated at a
    substance abuse treatment facility. It is well intended, but
    out dated, and Part 2 compromises medical care, increases the
    risk of dangerous and deadly adverse drug-to-drug interactions,
    and increases risk of relapse to addiction. My friend,
    Congressman Tonko from New York, and I have been working
    together to stop this medical records discrimination, and I
    thank him for his work.
        At the State level, responses to the epidemic vary. States
    like Indiana are responding to outbreaks of HIV and hepatitis.
    States on the east coast are confronting the problem of heroin
    laced with fentanyl, another narcotic pain reliever 100 times
    as powerful as morphine. Some States, mostly in the South, are
    burdened with the highest prescribing rates of opioid pain
    relievers, rates that are tenfold the rates in some other
    States. Also, State efforts share many similar challenges. The
    National Governors Association said States need accurate and
    timely information at their fingertips concerning the incidence
    and scope of the problem in order to develop an effective
    response. States have no choice but to use incomplete and
    outdated data to identify areas on which to concentrate their
    efforts, given their limited resources. Some States operate
    Prescription Drug Monitoring Programs, but these systems may
    not be easy to use. In Massachusetts, I believe it takes
    doctors 11 steps to use the program, which makes it difficult
    to encourage a high degree of participation. State systems are
    not necessarily connected to the systems of neighboring States,
    enabling abusers to doctor-shop across borders since their
    actions are not tracked. Further, the data on these systems can
    sometimes be several weeks old, escalating the risk for errors
    from inaccurate data.
        Overdose prevention remains a key aim of any meaningful
    State strategy, yet States have adopted different approaches to
    address it. Some provide liability protection for individuals
    who act in good faith to provide medical assistance to others
    in the event of an overdose, or expand access to the lifesaving
    drug naloxone, or use public education on the proper disposal
    of prescription drugs that are vulnerable to misuse.
        States also differ on availability and financing of
    medication-assisted treatments. Opioid maintenance is a bridge
    for those with addiction disorders to cross over in the
    recovery process, and we support that. Full recovery is
    complete abstinence. Medication-assisted treatment is valuable,
    but it must be coupled with proven psychosocial therapies and
    other wraparound services to support the person traversing this
    difficult road and to help with long-term, sustained recovery.
        Today we want to hear from the States about best-practice
    models, problems that they have encountered, and how States
    have addressed this problem. We also seek absolutely candid and
    honest input from each of our witnesses. Please tell us where
    there are problems, and please tell us where there are
    successes with any Federal programs or policies. We will hear
    from representatives of Indiana, Massachusetts, Missouri, and
    Colorado State Governments, a sampling of the 50-plus separate
    efforts being pursued by U.S. States and territories to counter
    opioid abuse. We are honored to have our witnesses join us this
    morning. We thank you for appearing today and look forward to
    hearing your testimony.
        [The prepared statement of Mr. Murphy follows:]

                     Prepared statement of Hon. Tim Murphy

        Today we convene the fourth in a series of hearings
    examining prescription drugs and heroin addiction; the growing
    nightmare of one of America's biggest public health crises.
    Since our opioid hearing earlier this month approximately 2,400
    Americans have died from drug overdoses, most of them because
    of opioid use.
        The size of this problem and the need for a new paradigm of
    treatment can't be understated. And, the process of developing
    legislative solutions has already started. Ranking Member
    DeGette and I have identified 15 areas in need of reform. One
    of those is 42 CFR Part 2, which governs confidentiality
    protections for all substance use treatment records, both
    behavioral and physical, generated at a substance abuse
    treatment facility. Well intended, but out dated, Part 2
    compromises medical care, increases the risk of dangerous and
    deadly adverse drug-to-drug interactions, and increases risk of
    relapse to addiction. Congressman Tonko from New York and I
    have been working together to stop this medical records
    discrimination. I thank him for his work.
        At the State level, responses to the epidemic vary. States
    like Indiana are responding to outbreaks of HIV and hepatitis.
    States on the east coast are confronting the problem of heroin
    laced with fentanyl, another narcotic pain reliever 100 times
    as powerful as morphine. Some States, mostly in the South, are
    burdened with the highest prescribing rates of opioid pain
    relievers, rates that are 10 fold the rates in some States.
        Also, State efforts share many similar challenges. The
    National Governors Association said States need accurate and
    timely information at their fingertips concerning the incidence
    and scope of the problem in order to develop an effective
    response. States have no choice but to use incomplete and
    outdated data to identify areas on which to concentrate their
    efforts given their limited resources.
        Some States operate Prescription Drug Monitoring Programs,
    but these systems may not be easy to use. In Massachusetts, it
    takes doctors 11 steps to use its program, which makes it
    difficult to encourage a high degree of participation. State
    systems are not necessarily connected to the systems of
    neighboring States, enabling abusers to doctor-shop across
    borders since their actions are not tracked. Further, the data
    on these systems can sometimes be several weeks old, escalating
    the risk for errors from inaccurate data.
        Overdose prevention remains a key aim of any meaningful
    State strategy, yet States have adopted different approaches to
    address it. Some provide liability protection for individuals
    who act in good faith to provide medical assistance to others
    in the event of an overdose or expand access to the life-saving
    drug naloxone or use public education on the proper disposal of
    prescription drugs that are vulnerable to misuse. States also
    differ on availability and financing of medication assisted
    treatments.
        Opioid maintenance is a bridge for those with addiction
    disorders to cross over in the recovery process. Full recovery
    is complete abstinence. Medication assisted treatment must be
    coupled with proven psycho-social therapies and other wrap-
    around services to support the person traversing this difficult
    road and to help with long-term, sustained recovery.
        Today we want to hear from the States about best-practice
    models, problems they have encountered, and how States have
    addressed these problems. We also seek absolutely candid and
    honest input and ideas about where there are problems and
    successes with any Federal policies.
        We will hear from representatives of the Indiana,
    Massachusetts, Missouri, and Colorado State Governments, a
    sampling of the 50-plus separate efforts being pursued by U.S.
    States and territories to counter opioid abuse.
        We are honored to have our witnesses join us this morning.
    We thank you for appearing today and look forward to hearing
    your testimony.

        Mr. Murphy. And I am purposefully cutting this short so we
    can keep this moving.
        Ms. DeGette. OK.
        Mr. Murphy. I 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 very much, Mr. Chairman. I have been
    asking you to have a hearing so we can hear from the States,
    and I am glad that the States are here. I think it is important
    because much of the work in this area is happening in the
    States.
        I am particularly glad that Dr. Wolk is here from my home
    State of Colorado. I am eager to hear about what is happening
    in Colorado, particularly the positive developments in reducing
    prescribing rates and illicit use of opioid painkillers. It is
    clear that if we wish to reduce the problem of opioid
    dependency in our communities, we also have to address the
    issue of overprescribing. Last year, the CDC released a report
    on the correlation between opioid prescribing rates and drug
    overdose rates. CDC Director Tom Frieden stated, ``Overdose
    rates are higher when these drugs are prescribed more
    frequently. States and practices where prescribing rates are
    highest need to take a particularly hard look at ways to reduce
    the inappropriate prescription of these dangerous drugs.''
        Colorado has taken a number of important steps to address
    the opioid epidemic at its source. In September 2013, statewide
    leadership established the Colorado Consortium on Prescription
    Drug Abuse Prevention; its goal is to reduce the misuse of
    prescription drugs through physician training and education,
    public outreach, and safe disposal. The goal of the coalition
    is also to prevent 92,000 Coloradans from misusing opioids by
    2016, and I am sure we can get a good progress report on that
    from Dr. Wolk. I know that Colorado has seen the rate of non-
    medical use of opioid painkillers fall already as a result of
    its work, and I am hoping we can hear about some of these best
    practices and lessons learned in this process.
        I am also eager to hear about how the other States here
    today are working to monitor prescribing rates, and reduce the
    number of opioid painkiller prescriptions. Experts tell us that
    the State Prescription Drug Monitoring Programs, or PDMPs, are
    an integral part of the solution to overprescribing. PDMPs can
    facilitate better clinical decision-making by prescribers,
    reduced doctor-shopping, and help physicians refer individuals
    for addiction treatment. I am interested to hear about the
    efforts that the States are undertaking to make PDMPs a more
    effective tool. For example, again, in Colorado, we were able
    to double our PDMP utilization rate from 41 percent to 84
    percent in just 1 year. Massachusetts also has high provider
    participation rates. I would like to know how we were able to
    achieve such great results in such a short time.
        Finally, I am interested to know more about the innovative
    efforts that States are undertaking on the treatment side of
    the equation. For instance, Missouri has made medication-
    assisted treatment available through all its State behavioral
    health organizations. The State does not contract with
    organizations that do not provide MATs. This is an important
    step to ensure that patients have access to the full evidence-
    based care that they need. Colorado is also taking steps to
    improve treatment for substance abuse disorders by integrating
    behavioral and primary care services in the State Medicaid
    Program. This is an ambitious goal of integrating 80 percent of
    the primary care practices with behavioral health services,
    including emergency departments, clinics, and private
    practices. I look forward to hearing more about this initiative
    and to similar efforts that are taking place in Massachusetts.
        So the States before us have made some impressive efforts
    to address this public health concern, but I want to caution
    that a lot more work needs to be done. Even before the opioid
    epidemic began, our infrastructure for treating substance abuse
    disorders in this country was remarkably inadequate to deal
    with the prevalence of the disease of addiction. Given the
    history of neglect and underinvestment in substance abuse, it
    is no wonder that the opioid epidemic resulted in a public
    health crisis.
        There is just one last thing I want to talk about, Mr.
    Chairman. We had a fellow show up just in the audience at our
    last hearing, Don Flattery, and Don came as a citizen because
    he lost his son, Kevin, to an opioid overdose last Labor Day,
    and when you hear about his son, Kevin, and when you hear about
    what this family went through, it is just heartbreaking. It is
    heartbreaking. I know all of our hearts go out to their family.
    They dedicated an immense amount of time and resources to
    getting the best treatment for Kevin, but they couldn't find
    access to the resources and quality treatment that they needed.
    I really want to thank Don for sharing his story with us, and
    for providing the committee with valuable insight into the
    problem. I am hoping we can hear from others like Don about the
    day-to-day challenges they face. Don wrote us a letter which
    talked about what has happened with his family, and I would ask
    unanimous consent to put that in the record, Mr. Chairman.
        [The letter appears at the conclusion of the hearing.]
        Mr. Murphy. Well, I agree, because I read the letter, too.
    It is powerful.
        Ms. DeGette. Yes. Thank you. And thanks again for holding
    this hearing, and I will yield back.
        Mr. Murphy. Yes, I just want to note too, I appreciate your
    request for doing this on a State level. I also want to
    acknowledge that I received a letter from you and Mr. Pallone
    on other suggestions for the committee. We do a lot of
    cooperative work together, and although that will never make
    the news that Members of Congress do work together on both
    sides of the aisle, I wanted to publically acknowledge my
    gratitude for you on that.
        Now, I don't know if there are any members on this side who
    want to make an opening statement, but I would like to give an
    opportunity to our colleagues from Indiana to introduce the
    witness from Indiana. Dr. Bucshon, are you going first or is
    Mrs. Brooks going first?
        Dr. Bucshon, you are recognized first.
        Mr. Bucshon. Thank you, Mr. Chairman. Today, I have the
    pleasure of introducing Indiana State Health Commissioner, Dr.
    Jerome Adams. Through extensive work as a researcher, as well
    as a policy leader, Dr. Adams brings a vast breadth of
    knowledge and experience to both the current opioid abuse
    epidemic in our State and to the witness panel. As we continue
    to work to curb the opioid abuse epidemic occurring through the
    country, parts of Indiana have recently seen HIV outbreaks as a
    direct result from this epidemic, presenting Dr. Adams with a
    unique challenge and a unique perspective on the current
    crisis. His expertise will undoubtedly be valuable to this
    committee.
        Dr. Adams, thank you for appearing before us today, and I
    look forward to your testimony.
        And I yield to Congresswoman Brooks from Indiana.
        Mrs. Brooks. Thank you, Dr. Bucshon.
        I want to thank the chairman for holding, once again, this
    important hearing, and to hear from witnesses who are battling
    this in our States. I want to extend a special welcome to Dr.
    Jerome Adams, my friend and constituent. It is wonderful for
    you to be here. And, in fact, his first day on the job, we were
    in an emergency meeting in Indianapolis focused on Ebola. And
    so here we are fast-forward just a few months, and I believe
    with your background not only as a physician from my medical
    school, but an anesthesiologist at Ball Memorial Hospital, that
    you do have the right kind of experience and background to help
    lead the State Health Department at this time. And as of May
    18, there have been 158 identified cases of HIV in Scott
    County, and that number has gone up from the time we last had a
    hearing, and we are asking the CDC about Scott County. And so
    we know that you and your team, many of whom are with you
    today, have done an amazing job of curbing the HIV epidemic and
    slowing its growth, and we look forward to hearing your
    testimony today.
        Thank you for being here.
        Mr. Murphy. Gentleman----
        Mr. Bucshon. Yield back.
        Mr. Murphy [continuing]. Yields back? All right, I
    recognize Mr. Pallone for 5 minutes.

    OPENING STATEMENT OF HON. FRANK PALLONE, JR., A REPRESENTATIVE
                IN CONGRESS FROM THE STATE OF NEW JERSEY

        Mr. Pallone. Thank you, Mr. Chairman. And I want to thank
    you and Ms. DeGette for the hearing, and for your due diligence
    in investigating the opioid abuse epidemic. I am glad the
    subcommittee is devoting significant attention to this issue
    because like all of the members here today, I am concerned
    about what is happening in my State.
        A New Jersey State official recently reported that more
    than 6,000 people in New Jersey have died from overdoses since
    2004. He also reported that more teens are dying from drug
    overdoses in New Jersey than car accidents. Today, we are
    hearing from State health officials about ongoing efforts
    within their agencies to combat this epidemic. And I know you
    all are dealing with many aspects of this issue, from reducing
    opiate prescribing rates, to increasing access to treatment to
    programs, and I look forward to hearing about the work you are
    doing, and I hope we can all learn from each other.
        I also want to hear from all the witnesses today about how
    we as the Federal Government can help fight this epidemic. We
    heard earlier this month from a number of Federal agencies
    about their work, but I want to make sure we are supporting the
    States and their efforts to address the epidemic.
        We have heard repeatedly throughout this series of hearings
    that significant barriers to treatment for substance use
    disorders still exist. For example, SAMHSA's 2013 National
    Survey on Drug Abuse and Health found that nearly 40 percent of
    individuals who make an effort to seek treatment were unable to
    get treatment due to lack of health coverage and the
    prohibitive cost of treatment. Another 8 percent reported that
    they had health coverage but it did not cover the cost of
    treatment. And with the passage of the Affordable Care Act,
    approximately 16.4 million Americans have gained health
    insurance coverage, and insurance companies are now required to
    provide treatment for substance abuse disorders and coverage,
    just as they would cover treatment for any other chronic
    disease. But we still need to understand where barriers to
    treatment remain, and we should work on making sure those who
    want to access treatment are able to do so.
        I also want to hear from all of our witnesses today about
    how Medicaid expansion, or in Missouri's case of failure to
    expand Medicaid, has had an impact on treatment for substance
    abuse disorders. I know Massachusetts and Colorado both signed
    Medicaid expansions into law in 2013, and Indiana expanded
    Medicaid earlier this year, so I am interested to hear from all
    three of your States about how Medicaid expansion has improved
    access to behavioral health services, and I want to hear from
    Missouri how Medicaid expansion could help those seeking access
    to behavioral health services and what challenges you face by
    not expanding the program. So thanks again.
        [The prepared statement of Mr. Pallone follows:]

                 Prepared statement of Hon. Frank Pallone, Jr.

        Mr. Chairman, thank you for holding today's hearing and for
    your due diligence in investigating the opioid abuse epidemic.
    I'm glad this subcommittee is devoting significant attention to
    this issue because like all of the Members here today, I am
    concerned about what is happening in my State.
        A New Jersey State official recently reported that more
    than 6,000 people in the State have died from overdoses since
    2004. He also reported that more teens are dying from drug
    overdoses in New Jersey than car accidents.
        Today, we are hearing from State health officials about
    ongoing efforts within their agencies to combat this epidemic.
    I know you all are dealing with many aspects of this issue,
    from reducing opioid prescribing rates to increasing access to
    treatment to programs.
        I look forward to hearing about the work you are doing, and
    I hope you all can learn from each other as well.
        I also want to hear from all of the witnesses today how we
    as the Federal Government can help fight this epidemic. We
    heard earlier this month from a number of Federal agencies
    about their work, but I want to make sure we are supporting the
    States in their efforts to address the epidemic.
        We have heard repeatedly throughout this series of hearings
    that significant barriers to treatment for substance use
    disorders still exist. For example, SAMHSA's 2013 National
    Survey on Drug Use and Health found that nearly 40% of
    individuals who made an effort to seek treatment were unable to
    get treatment due to lack of health coverage and the
    prohibitive cost of treatment. Another 8% reported that they
    had health coverage, but it did not cover the costs of
    treatment.
        With the passage of the Affordable Care Act, approximately
    16.4 million Americans have gained health insurance coverage.
    And insurance companies are now required to provide treatment
    for substance abuse disorders and cover it just as they would
    cover treatment for any other chronic disease.
        But we still need to understand where barriers to treatment
    remain, and we should work on making sure those who want to
    access treatment are able to do so.
        I also want to hear from all of our witnesses today about
    how Medicaid expansion--or in Missouri's case, a failure to
    expand Medicaid--has had an impact on treatment for substance
    abuse disorders. I know Massachusetts and Colorado both signed
    Medicaid expansion into law in 2013, and Indiana expanded
    Medicaid earlier this year.
        I'm interested to hear from all three of your States about
    how Medicaid expansion has improved access to behavioral health
    services. And I want to hear from Missouri how Medicaid
    expansion could help those seeking access to behavioral health
    services and what challenges you face by not expanding the
    program.
        Thank you again for holding this hearing, and thank you to
    all our witnesses for sharing your insight today.
        I yield my remaining time to Rep. Kennedy.

        Mr. Pallone. I would like now to yield the rest of my time
    to Representative Kennedy.
        Mr. Kennedy. Thank you. I would like to thank the ranking
    member. I would also like to thank the chairman of the
    committee for calling this extraordinary series of hearings.
    They have been, I think, extremely enlightening, and shining a
    light on an incredible epidemic our country is facing.
        To the witnesses today, thank you so much for being here to
    discuss the States' efforts to combat opioid abuse. In my mind,
    we are here for one reason; to learn from you about what has
    worked on the ground in your States, and how we can try to
    support those efforts at a Federal level in any way possible.
        Few in my home State have been spared the tragic
    consequences of the ongoing opioid epidemic. Last year, there
    were more than 1,000 deaths in our Commonwealth, spanning
    wealthy and low-income communities alike, areas rural and
    urban, faces young and old.
        Dr. Bharel has been on the frontlines of this battle for
    long before she was appointed to the Public Health Commission
    earlier this year, but in her new role, she is focused on
    ensuring treatment options are available to all of our
    citizens, regardless of income. It is my honor to welcome her
    today to Washington, and I look forward to hearing your
    testimony.
        One issue I hope to hear from all of you today is a little
    bit about one of the issues we have been wrestling with in
    Massachusetts, which is the rising cost of Narcan. At a time
    when our country needs every tool at its disposal in this
    fight, the price of lifesaving treatment continues to
    skyrocket. Last month in Needham, Massachusetts, the cost per
    dose rose to $66.89, up from $19.56 last June.
        Now, Narcan is by no means an answer to this epidemic. It
    is a stopgap, not a solution, but it does save lives. It allows
    us to get individuals suffering from crippling addiction into
    treatment. It helps minimize the number of parents, brothers,
    sisters, and children with loved ones who are taken far too
    soon. So I would be interested to hear from our witnesses about
    any price spikes that you have seen at home, how those have
    impacted response efforts, and how the Federal Government can
    help ensure that no one's life is lost because a municipality
    simply can't afford a drug.
        Another area that I would like to get some insight on is
    the effectiveness of Prescription Drug Monitoring Programs. I
    represent a district in Massachusetts that borders Rhode
    Island, and it has become clear to me that the lack of
    communication across State lines is leaving a gap in how we
    tackle prescription drugs. To that end, I helped to cosponsor
    the National All Schedules Prescription Electronic Reporting
    Act with Congressman Whitfield in an effort to better support
    State PDMPs, particularly where interoperability is concerned.
    Drs. Adams, Bharel, Wolk, I hope you will expand a little bit
    more on the roles PDMPs have played in your States' efforts
    today. Dr. Stringer, I would love if you would be able to touch
    a little bit about your State's plans to develop a PDMP.
        Tackling an epidemic of this scope requires partners across
    local, State, and Federal levels. To that end, we are all
    deeply grateful for your presence here today, and look forward
    to supporting you any way we can.
        Thank you, and I yield back.
        Mr. Murphy. Gentleman yields back.
        I would now like to introduce the witnesses on the panel
    for today's hearing. We have already heard about Dr. Jerome
    Adams, the Health Commissioner of the Indiana State Department
    of Health. Welcome. Dr. Monica Bharel, the Commissioner of the
    Massachusetts Department of Health. Dr. Larry Wolk, the
    Executive Director and Chief Medical Officer at the Colorado
    Department of Public Health and Environment. And Mr. Mark
    Stringer, the Director of the Division of Behavioral Health at
    the Missouri Department of Mental Health.
        I would now like to swear in the witnesses.
        You are all aware that the committee is holding an
    investigative hearing, and when doing so, has the practice of
    taking testimony under oath. Do any of you have any objections
    to testifying under oath? All the witnesses answered negative.
    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
    today? All the witnesses indicate no. In that case, if you will
    all please rise and raise your right hand, I will swear you in.
        [Witnesses sworn.]
        Mr. Murphy. You are now under oath and subject to the
    penalties set forth in Title XVIII, Section 1001 of the United
    States Code. You may now each give a 5-minute summary of your
    written statement, and please try to be under 5 minutes. You
    will need to press the button so the green light is on, and
    pull the microphone fairly close to you. Thank you.
        Dr. Adams, you are recognized for 5 minutes.

    STATEMENTS OF JEROME ADAMS, M.D., M.P.H., COMMISSIONER, INDIANA
       STATE DEPARTMENT OF HEALTH; MONICA BHAREL, M.D., M.P.H.,
    COMMISSIONER, MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH; LARRY
      WOLK, M.D., M.S.P.H., EXECUTIVE DIRECTOR AND CHIEF MEDICAL
    OFFICER, COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT;
    AND MARK STRINGER, M.A., L.P.C., N.C.C., DIRECTOR, DIVISION OF
        BEHAVIORAL HEALTH, DEPARTMENT OF MENTAL HEALTH, MISSOURI

                       STATEMENT OF JEROME ADAMS

        Dr. Adams. Thank you very much. My name is Jerome Adams. I
    am the Indiana State Health Commissioner, I am a physician
    anesthesiologist, and I am the brother of an addict. On behalf
    of Governor Mike Pence and the people of Indiana, it is my
    honor to be here today.
        In rural Scott County, we are dealing with the largest
    injection-drug-use-related HIV outbreak in decades, with what
    CDC Director Tom Frieden described as a higher incidence of HIV
    than any country in sub-Saharan Africa. In an area that had
    three total cases of HIV over the prior 4 years, we, as of
    today, have 160 positives, with 95 percent related to injection
    drug use, and Hepatitis C co-infection rate of 88 percent.
        At the root of this outbreak is our country's prescription
    opioid crisis. The crisis is multifactorial, but I think it is
    helpful to separate it into three distinct problem and solution
    areas. Number one, we need to stop the flow of opioids into
    communities. Number two, we need to deal with the personal and
    public health consequences of communities with overflow of both
    opioids and people engaging in high-risk activities. And number
    three, we need to create an outlet for those seeking recovery
    from substance use disorder.
        In terms of stopping the flow, in Indiana we witnessed a 10
    percent decrease in prescriptions since we implemented new
    opioid prescribing rules in 2012, but we still have work to do.
    We need an aggressive education and prevention strategy
    starting in childhood. In addition to promoting the dangers of
    prescription drug misuse, we need better Prescription Drug
    Monitoring Programs with required reporting from the VA and
    Federal methadone treatment centers, higher thresholds for new
    FDA approvals of opioids, and safety and efficacy reviews of
    previously approved opioids based on recent data. Policies
    should further promote pharmacy and community opioid take-back
    programs, and require opioid manufacturers to facilitate these
    endeavors. And we should revisit both pain as the fifth vital
    sign, and the pain component of patient satisfaction as a
    consideration for physician and hospital reimbursement. Our
    focus needs to be on functionality and outcomes, and not simply
    on stopping pain with pills.
        Regarding the consequences of opioid overflow, we have seen
    not just an HIV epidemic, but also regional epidemics of
    Hepatitis, overdose deaths, unsustainable levels of
    incarceration, and community hopelessness. Our comprehensive
    approach in Scott County includes increased HIV and Hepatitis
    testing, and immediate treatment referral, locally based harm
    reduction strategies, immunizations, healthcare coverage, job
    training, and an outreach campaign targeting drug users and
    those involved in the commercial sex trade.
        On a State level, we have formed a Neonatal Abstinence
    Syndrome Committee, and recently made Naloxone available for
    first responders and friends or family members of those at
    risk. As Governor Pence said when he signed our Naloxone Bill,
    bills like this are about saving lives. Thanks to Governor
    Pence fighting hard to receive the only Federal waiver of its
    kind, and to Representative Pallone's point, we can further
    address the needs of those with substance use disorder,
    including healthcare coverage and access, the two are not
    equal, and job training via our Healthy Indiana Plan. If people
    don't have hope, they will increasingly turn to and stay on
    drugs; a painful lesson we have learned from Scott County.
    Fortunately, over 225,000 Hoosiers have more hope now thanks to
    HIP 2.0.
        Lastly, in terms of creating an outlet, we must provide
    options for those seeking recovery services. A national
    campaign could reduce the stigma of substance use disorder and
    HIV so people aren't ashamed to seek services, and could help
    reframe addiction from that of a moral failure to that of a
    medical disorder that requires a lifetime of attention. Lack of
    recovery reflects a lack of enlightenment on society's part, as
    much of it reflects a lack of earnestness on the sufferer's
    part.
        Regarding recovery in Scott County, we have found a severe
    and unmet need for access to appropriate substance use disorder
    treatment, and we have accordingly worked to increase beds in
    outpatient services. When incarcerated, sufferers also should
    have access to mental health and addiction treatment, with
    linkages to these services upon release. Such programs exist in
    Indiana, but are often only found in the most well-resourced
    communities. And we must educate communities and the public
    about medication-assisted treatment as an important component
    of the recovery safety net. Recently enacted legislation in
    Indiana allows the establishment of additional methadone
    clinics in our State, and the criminal justice system at the
    county level is increasingly offering Vivitrol for inmates upon
    release, or as an option during drug court diversion programs.
        Our situation in Indiana, in closing, may be unprecedented
    in many ways, but in many others, it illustrates problems faced
    throughout our country. There is much we do, but I am confident
    that we can succeed. If we focus on education, patient-centered
    care, and community and patient empowerment, I am confident we
    can successfully combat the scourge of opioid abuse.
        Mr. Chairman, thank you for your time, and I look forward
    to the opportunity to answer your questions.
        [The prepared statement of Dr. Adams follows:]

        [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Mr. Murphy. Thank you very much, Doctor.
        And now, Dr. Bharel, you are recognized for 5 minutes.

                       STATEMENT OF MONICA BHAREL

        Dr. Bharel. Thank you, Chairman Murphy, Ranking Member
    DeGette, and the members of the committee. Thank you for
    welcoming us here today, and for the opportunity to provide
    this testimony on this incredibly pressing issue today.
        My name is Dr. Monica Bharel, and I am proud to have been
    appointed to serve the Commonwealth of Massachusetts and
    Governor Baker as its Commissioner of Public Health. I am
    honored to be here representing one of the Nation's oldest
    public health departments; one that traces its roots back to
    Commissioner Paul Revere, and one that has continually led the
    way in public health across the country. Yes, we can talk more
    about that later.
        As a----
        Mr. Murphy. He alerted people with lanterns, I am aware of
    that. So----
        Dr. Bharel. He gave out information on cholera throughout
    the Commonwealth.
        As a frontline physician and as a former Chief Medical
    Officer at Boston Healthcare for the Homeless Program, the
    largest of its kind in the Nation, I have seen firsthand the
    rising tide of an opioid epidemic that is overwhelming
    communities. We have watched our family and friends die on our
    streets, driven by a lethal cocktail of trauma and underlying
    behavioral health issues. This is not something we as a society
    should accept as the norm.
        This epidemic will be far from easy to tackle, but this
    challenge is precisely what drew me here to work with you and
    our providers, our community leaders.
        To that end, we are already hard at work in Massachusetts
    and throughout the Baker administration, redoubling our efforts
    to identify, triage, address, and treat the opioid epidemic.
        First, to identify the problem. Like so many States across
    the Nation, Massachusetts is facing a growing epidemic of
    opioid addiction and overdose deaths. In 2013, there were 967
    unintentional opioid deaths, compared to 371 motor-vehicle-
    related injury deaths. That is 2 \1/2\ times as many people
    dying from opioid use as for motor-vehicle-related injuries.
    And behind those 967 deaths are over 2,000 hospital stays and
    more than 4,500 emergency room visits, and of course,
    unquantifiable human suffering. And in 2014, we have projected
    estimations of over 1,000 people dying of an opioid-related
    overdose. This is a 51 percent increase from 2012. We will fail
    in our efforts to address this crisis if we do not fully
    involve partners from all sectors. That includes law
    enforcement, public health, healthcare institutions, families,
    schools, and you, our elected officials.
        Governor Baker prioritized the opioid epidemic early in his
    new administration. In February, Governor Baker appointed 18
    individuals to serve on his Opioid Working Group. The group
    represents the many different perspectives that are important
    to this work, and was charged with developing tangible
    recommendations. The working group has held listening sessions
    across the Commonwealth, hearing from over 1,100 individuals,
    and receiving hundreds of recommendations and emails. No matter
    which of the lens these individuals look at this epidemic, one
    thing is obvious, that opioids are impacting every city and
    town in the Commonwealth. People speak again and again about
    the wish to have early prevention and increased access to
    treatment.
        Our success getting to the underlying health issues and
    social determinants that are driving this epidemic; trauma, and
    undiagnosed behavioral health issues are chief among those,
    will directly correlate with our ability to successfully
    leverage data and to measure results. This data will allow us
    over time to effectively target key populations and hotspot, if
    you will, to better understand the impact of our collective
    efforts, and how to use our limited resources better.
    Utilization of data to combat the opioid crisis has a long way
    to go. For example, currently in our Department of Public
    Health we have more than 300 different internal data systems
    that have developed by individual programs and use a variety of
    different formats. They are managed by different staff, and
    reside on different servers that don't talk to each other.
    However, this problem is not unique to Massachusetts, and
    across the country, public health needs to double down on data
    and on interoperable secure IT solutions, such as data
    warehousing, to create better linkages between our siloed data
    sets.
        As a frontline clinician, I have experienced firsthand the
    real roadblocks to helping patients access care. In the area of
    access, particularly with regards to downstream post-detox
    care, individuals have had a lot of trouble with both
    residential and outpatient medication treatment service
    availability. In capacity, statewide bed capacity, the kinds of
    bed types available and how to access them are not well known.
    Services for mothers and fathers in recovery who are attempting
    to reclaim their lives, while trying to take care of their
    children, needs improvement. Individuals suffering from
    addiction need better access to childcare, stable housing, and
    employment opportunities, as well as access to timely
    treatment. We need more early interventions in schools, and
    perhaps most important, this issue of stigma.
        What this hearing alone represents is an important step
    towards societal recovery. We need to talk about this disease.
    This is a chronic disease, and as a community and a nation, we
    will treat it and we will find pathways to recovery together by
    first speaking of it as a chronic disease. From the bedsides to
    the halls of bureaucracy, addressing this opioid crisis
    requires taking action across the spectrum of prevention,
    intervention, treatment, and recovery support. At DPH, we are
    proud of the progress we have made in areas such as access to
    Naloxone kits, with the cities of Quincy and Gloucester being
    some of the first communities in the Nation to arm themselves
    with Naloxone. Beyond saving lives, this measure has changed
    attitudes with police no longer arresting their way out of this
    epidemic, but looking towards solutions.
        Mr. Murphy. I will need you to wrap up, if you could.
        Dr. Bharel. Sure. And as a medical community, we know that
    20 percent of pain relievers for nonmedical use are coming
    directly from clinicians, so we as clinicians must shift our
    expectations of practices that opioids are not the first line
    of defense. However, as our national data sets demonstrate,
    more than 80 percent of lethal painkillers come from non-
    clinicians. And so, again, this highlights the element of truth
    of working across partnerships.
        And I look forward to answering any further questions you
    have. Thank you.
        [The prepared statement of Dr. Bharel follows:]

        [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Mr. Murphy. Thank you very much.
        Dr. Wolk, recognized for 5 minutes.

                        STATEMENT OF LARRY WOLK

        Dr. Wolk. Thank you, Chairman Murphy, Ranking Member
    DeGette, and members of the subcommittee for the opportunity to
    provide testimony to you today about our efforts to address the
    opioid epidemic in Colorado.
        In 2012, we had the troubling distinction of ranking second
    nationally for self-reported, nonmedical use of prescription
    drugs. More than \1/4\ million Coloradans misused prescription
    drugs, and consequent deaths related to misuse nearly
    quadrupled between 2000 and 2011. Drug overdose remains the
    leading cause of injury death in Colorado, and almost 11
    percent of Coloradans aged 18 to 25 still engage in nonmedical
    use of prescription drugs. In the last 5 years, the number of
    heroin users in Colorado has also doubled, and we are
    challenged with concerns that existing treatment capacity is
    not meeting a rising demand, as treatment admissions for heroin
    and prescription opioid abuse increased 128 percent between
    2007 and 2014. However, recent data suggests that we are
    heading in a better direction. 2013 data released shows that
    our rate on nonmedical use has decreased from 6 percent to
    nearly 5 percent, which represents 39,000 fewer Coloradans who
    misused prescription drugs. Additionally, the Colorado youth
    use rate is decreasing and is now below the national average.
    Since 2012, catalyzed by Governor Hickenlooper's leadership as
    the co-chair of the NGA's Policy Academy for reducing
    prescription drug abuse, we are currently implementing a
    coordinated approach, setting as our goal to prevent 92,000
    Coloradans from engaging in nonmedical use of prescription pain
    medications through the adoption of our Colorado plan to reduce
    prescription drug abuse. This commitment represents a reduction
    from 6 percent to 3 \1/2\ percent of Coloradans who self-report
    nonmedical use of prescription drugs, focusing on seven key
    areas: improved surveillance of prescription drug misuse data;
    strengthening the Colorado PDMP; educating prescribers and
    providers; increasing safe disposal; increasing public
    awareness; enhancing access to evidence-based effective
    treatment; and expanding access to the overdose reversal drug,
    Naloxone.
        To monitor and coordinate progress, State-level leadership
    created the Colorado Consortium for Prescription Drug Abuse
    Prevention. The consortium provides a statewide, interagency,
    interuniversity framework designed to facilitate the
    collaboration and implementation of the strategic plan, and is
    comprised of seven work groups. For one, the Data and Research
    Work Group of the consortium has worked to map out all sources
    of data related to prescription drug use, misuse, and overdose
    in the State. Second, the PDMP Work Group has worked over the
    past 2 years to enhance our State's PDMP as an effective public
    health tool. As of July 2014, our PDMP utilization rate was 41
    percent, and in April 2015, that rate more than doubled,
    reaching 85 percent. How did we accomplish this dramatic
    improvement? We recently implemented push notices to both
    prescribers and pharmacists when patients visit a certain
    number of prescribers and pharmacies to obtain a controlled
    substance. We require PDMP registration for pharmacists and
    DEA-registered prescribers, but we allow prescribers and
    pharmacists to assign and register delegates in their office,
    because they are often busy, so that those delegates can check
    the PDMP. We have also enhanced the PDMP interface and moved to
    a daily upload of data so that it is constantly refreshed. The
    Provider Education Work Group focuses on issues related to
    improving the education and training of healthcare
    professionals through a jointly developed policy; a policy that
    has since been adopted by the dental, medical, nursing,
    pharmacy, optometry, and podiatry Boards in Colorado. It is the
    first joint policy of its type adopted by multiple regulatory
    Boards. As of October 2014, over 1,300 prescribers had
    completed the training developed from this policy, and 87
    percent indicated that they intended to change their practice
    as a result. We were encouraged because the CDC morbidity and
    mortality report recently ranked Colorado 40th nationally for
    prescribing rates of opioids, fiftieth being the lowest rate of
    prescribing.
        The Safe Disposal Work Group focuses on issues relating to
    safe storage and disposal of prescription medications, with the
    potential for misuse, abuse, or diversion, knowing that more
    than 70 percent of those who abuse obtain them from the unused
    supplies of family and friends. This work group developed
    guidelines and outreach efforts, and expanded the number of
    safe disposal sites throughout the State. By next year, we have
    plans to provide drop boxes in every county in the State.
        Public Awareness Group has developed a new statewide
    advertising and public outreach campaign called Take Meds
    Seriously. Our consortium's Treatment Work Group has focused on
    identifying gaps in the need for medication-assisted treatment.
    And our Naloxone Work Group focuses on increasing awareness of
    and access to Naloxone, making clinical, organizational, and
    public policy recommendations to achieve this goal.
        I thank you for the opportunity. I see that I am out of
    time, and thank you.
        [The prepared statement of Dr. Wolk follows:]

        [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Mr. Murphy. Thank you, Dr. Wolk.
        Mr. Stringer, you are recognized for 5 minutes.

                       STATEMENT OF MARK STRINGER

        Mr. Stringer. Chairman Murphy, Ranking Member DeGette, and
    members of the subcommittee, my name is Mark Stringer and I am
    the Director of the Division of Behavioral Health in the
    Missouri Department of Mental Health. I also have the privilege
    of serving as President of the Board of the National
    Association of State Alcohol and Drug Abuse Directors, or
    NASADAD. It is truly an honor to offer remarks this morning
    about what Missouri is doing regarding the opioid problem in
    particular, and addiction in general.
        If there is a theme running through our messages this
    morning, I believe one of the most important ones is that
    access to treatment and recovery services is essential to
    addressing this problem.
        On this very day in Missouri, nearly 3,000 people are on
    waiting lists for substance use disorder treatment services.
    That equates to about 43,000 Missourians waiting for help
    during the course of a year. What is truly sad about this is
    that often a person seeks treatment after some kind of a life-
    altering event, a run-in with the law, a problem at work, some
    type of illness, an overdose. So every name on a waiting list
    is a potential tragedy for an individual, a family, and a
    community. In order to be successful, services must be
    accessible. They have to be individually tailored, evidence-
    based, and they must include recovery supports. One thing I
    know with certainty after 30 years in this field is that
    treatment cannot be effective and treatment cannot possibly
    work if you can't get access to it when you need it.
        So I will give you some just quick information about my
    State of Missouri. We estimate that about 400,000 Missourians
    have substance use disorders. Last year, 43,000 actually
    received treatment services through the publicly funded system.
    With regard to opioids, Missouri saw 124 percent increase in
    treatment admissions related to prescription drugs from 2007 to
    2012, and 125 percent increase in admissions related to heroin.
    We lose about 200 people to heroin deaths each year; most of
    them in eastern Missouri, including St. Louis.
        Here are some steps we are taking to deal with the problem.
    We developed a statewide plan for coordinated treatment and
    recovery services, and we partner with providers to ensure that
    services are high quality and evidence-based. One tool for
    promoting quality is our contracting authority; building in
    certain requirements that providers must follow as a condition
    of receiving State funds. We perform on-site certification
    reviews to assure that providers are adhering to standards of
    care that are set by the State. As an example, we use these
    tools to require that all addiction treatment providers in
    Missouri who are, again, contracted with the State make
    medication-assisted treatment available, either directly or by
    referral. This took time, resources, and education, and it is a
    work in progress but it is the right step for Missouri. We have
    also worked hard to leverage SAMHSA's Access To Recovery
    program, or ATR, to build a statewide system of recovery
    services. Prevention is critical. Our State has a strategic
    plan for prevention, with a focus on prescription drug abuse.
    And we have partnered with a group, just as an example, in a
    college setting we have a group called Partners in Prevention,
    that is a coalition of 21 college campuses located throughout
    Missouri, which is working specifically on prescription drug
    abuse among college students. This effort has made a
    difference. From 2013 to 2014, we have seen a 10 percent
    decrease in the misuse of prescription drugs among college
    students.
        There are other initiatives in my written testimony, but I
    will now turn to a few recommendations. I recommend that all
    Federal initiatives specifically include involvement of State
    substance abuse agencies, like mine. Given their expertise and
    authority over the addiction prevention, treatment and recovery
    systems. And I particularly want to recognize the Director of
    the Office of National Drug Control Policy, Michael Botticelli,
    for his efforts to coordinate drug policy across Federal
    Government, and to keep States informed and engaged.
        Second, I recommend strong support for the Substance Abuse
    Prevention and Treatment Block Grant, a vital part of the
    public safety net for treatment that also provides an average
    of 70 percent of State substance abuse agencies' funding for
    primary prevention.
        Third, I support specific initiatives to increase the
    availability of all FDA-approved medications for substance use
    disorders, and I applaud the administration's proposed $25
    million for States to expand opioid treatment services where
    medication-assisted treatment is an allowable use of funding.
        Fourth, I recommend specific resources to help States and
    localities purchase Naloxone. This would have an immediate
    lifesaving impact, and I appreciate the administration's
    proposal to provide $12 million within SAMHSA for overdose
    reversal and prevention activities. I certainly support
    mandatory prescriber education and training on substance use
    disorders. And finally, I encourage Congress and the
    administration to continue to work with State-based groups
    heavily involved in this issue, including groups like the
    National Association of State Alcohol and Drug Abuse Directors,
    the Association of State and Territorial Health Officers, but
    also our parent group, the National Governors Association,
    which has provided critical leadership in this area.
        Thank you for the opportunity to testify, and I look
    forward to answering questions.
        [The prepared statement of Mr. Stringer follows:]

        [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Mr. Murphy. I thank all the panelists.
        I will now recognize myself for 5 minutes of questions.
        Mr. Stringer, your office sits within Missouri's Department
    of Mental Health, and in the course of your work, have you
    found that Federal policies, including those affecting the ways
    in which certain treatment options are funded, have hampered
    any mechanism to treat individuals with co-occurring substance
    abuse and mental health disorders, and if so, what can be done,
    what do you suggest we do to correct that?
        Mr. Stringer. Mr. Chairman, I am not sure it is a policy
    issue. I am going to try to answer that yes or no. Yes. Yes,
    there are some things that get in the way of treating people
    with co-occurring disorders. Primarily has to do with funding
    screens, how funding comes to the States, what the limitations
    are, and how those funds are spent.
        We have been successful in Missouri, I think, at braiding
    funds for people with co-occurring disorders, and so we treat
    some--so what we have done is really enhance our substance use
    disorder programs to include some mental health services. We
    have enhanced our community mental health services to include
    substance use disorder services. So we have been able to do
    that with the flexibility that is already there.
        Mr. Murphy. I asked that because we have had other
    witnesses say they would like to let the Federal Government
    merge some of those funds so they can treat both.
        I would like to open this question up to all of you. I made
    some comments in my opening statement regarding the 42 C.F.R.,
    and some concerns it has with interfering with doctors' ability
    to provide safe and effective treatment for patients. I don't
    know if any of you have reports from the State, but let me
    elaborate on this. A basic quality measure of good healthcare
    is medication reconciliation, as you are aware, which means
    assessing and documenting all the medications someone may be
    taking, which would include buprenorphine, Vivitrol, or all
    these other ones, but as a result of the 42 C.F.R. Part 2, a
    doctor's ability to complete these medication reconciliations
    is very compromised. As I said, Mr. Tonko and I are working on
    this, so a patient may be getting Suboxone from an addiction
    medication physician, but this person may fail to inform their
    family physician, who may recommend another thing, or you can
    have someone on Vivitrol and--doesn't tell a physician, and
    next thing you know, they get a pain medication, an opiate, and
    now you have someone who either has a risk of death, or you
    increase their risk for relapse. And I wonder if any of you can
    comment. Do you have any suggestions on this? Dr. Wolk, you are
    nodding your head. You have some comments on that?
        Dr. Wolk. Thank you, Mr. Chair. Prior to assuming this role
    2 years ago, I was the CEO for the State's Health Information
    Exchange, CORHIO. And you highlight a very big obstacle when it
    comes to exchanging and making available clinical information
    to all providers involved in a patient's care. If the health
    information exchange is going to work with regard to reducing
    duplication, improving quality, and reducing cost, the
    healthcare provider has to have access to all of the patient's
    information, whether it is physical, mental health, or
    substance abuse-related. So----
        Mr. Murphy. And we do have barriers that mental health
    therapy notes don't get into those things, which is--OK. That
    is a good point.
        I want to follow up with one. Dr. Adams, I want to catch
    you before my time is out here. The diversion of buprenorphine
    for illicit nonmedical use is a significant problem, and that
    is just a part of the reason why the opioid epidemic is
    spreading. According to the Drug Enforcement Administration,
    buprenorphine is the third most seized prescription opiate by
    law enforcement. And so is the diversion of buprenorphine a
    significant problem in your State, and how are you handling
    that?
        Dr. Adams. It is a significant problem in parts of our
    State, and that is why we need to have a larger conversation
    about medication-assisted treatment and what it can and cannot
    do. Vivitrol, for instance, is a wonderful drug for a very
    small subset of the population. Methadone, we need to separate
    the discussion between methadone for chronic pain versus
    methadone for substance abuse treatment in medication-assisted
    therapy. And so again, I would promote educational campaigns
    both for the public, for policymakers, and for physicians,
    quite frankly, in terms of what can and can't be accomplished.
    And Suboxone is a great drug, again, for a certain subset of
    the population, when done right, but we have found when done
    wrong, diversion can occur, and that is a concern that has been
    brought up by particularly our correctional facilities where
    people say they can easily sneak it in to the correctional
    facilities.
        Mr. Murphy. I appreciate that. And my time is almost up,
    but this is the kind of thing we are going to want you to
    comment on. In addition, we made reference before to Don
    Flattery's letter to us, and he brings up an important point
    here that opiate pain relievers, or OPRs, can worsen chronic
    pain over time. And that is another area, it seems to me, as
    you are recommending we need to do much more in education--
    mandatory education of physicians and prescribers on that. So
    keep that thought in mind, we are going to want some input on
    that too.
        I now recognize----
        Dr. Adams. Mr. Chairman, one thing you can do concretely is
    you can have the VA and you can have Federal methadone programs
    report to Prescription Drug Monitoring Programs. You all can do
    that, and that will help get information out to the physicians.
        Mr. Murphy. Excellent, thank you. Thank you.
        Ms. DeGette, 5 minutes.
        Ms. DeGette. Well, thank you. This sort of follows up on
    your line of questioning, Mr. Chairman.
        Dr. Wolk, I wanted to talk to you about the Prescription
    Drug Monitoring Program a little bit, and what we have done in
    Colorado, we passed a law in Colorado that now requires medical
    professionals who prescribe powerful controlled substances to
    sign up for an account. Is that right, Dr. Wolk?
        Dr. Wolk. Thank you, Representative DeGette. That is
    correct.
        Ms. DeGette. And since Colorado implemented that law, the
    use rate of the PDMP has doubled, going from about 40 to 85
    percent in less than a year. Is that right?
        Dr. Wolk. Thank you, Representative DeGette. That is also
    correct.
        Ms. DeGette. And do you think that mandating the need to
    have an account with the PDMP is the key to Colorado's higher
    provider utilization rates? Is this something you think other
    States should consider?
        Dr. Wolk. Thank you, Representative DeGette. I do. In
    addition to having the allowance for a delegate in the
    prescriber's office, because mandated participation--but then
    actual participation is enhanced by allowing that delegate to
    be assigned----
        Ms. DeGette. Um-hum.
        Dr. Wolk [continuing]. To work on behalf of the provider.
        Ms. DeGette. OK. And I understand also that key medical
    Boards within the State came together, as we do in Colorado
    because that is the way we are, to create prescribing
    guidelines for opioid therapies. Can you talk about how this
    guidance is helping to guide Colorado doctors and dentists in
    their prescribing practices?
        Dr. Wolk. Thank you, Representative DeGette. It is a policy
    that was developed, and then a training from that policy, and
    because of the universal endorsement or adoption by all of
    those different Boards of healthcare professionals that are in
    a position to prescribe, we really have seen a universal
    acceptance, high numbers of participation, and a very high
    number 87 percent, who said they would change their practice
    now as a result of that training.
        Ms. DeGette. So when were all of these guidances, what year
    were they adopted?
        Dr. Wolk. Thank you, Representative DeGette. It is within
    the past 2 years.
        Ms. DeGette. OK, because you had some alarming statistics
    in your testimony about the way opioid use was going up in
    Colorado, and now we seem to be bringing it down. Do you think
    that these new guidelines have helped towards that goal?
        Dr. Wolk. Thank you, Representative DeGette. I do think
    that they have, and we have some preliminary data coming in for
    2014 that shows further stabilization, at least on the
    prescriptive opioids.
        Ms. DeGette. And, Dr. Adams, I wanted to ask you, I
    understand that Indiana has adopted mandatory prescribing
    guidelines for opioid therapies. Can you talk to us about how
    the guidelines work, and what impact that they have had on this
    overprescribing problem?
        Dr. Adams. Well, again, we have seen a 10 percent drop in
    prescribing since we have instituted our opioid prescribing
    rules. And I will tell you, I was on the State Medical
    Association Board of Trustees when these rules were coming
    through. Education is paramount any time you are trying to
    prescribe what doctors are and are not going to do.
        As far as high points, we have an overall threshold in
    terms of if you go over 60 pills per month or 15 milligrams per
    day for over 3 consecutive months, you have to abide by these
    rules. There is a mandatory assessment which includes an H&P,
    and unfortunately we found people were prescribing pills
    without actually seeing patients or doing a full exam.
        Ms. DeGette. Um-hum.
        Dr. Adams. There are regular visits if you are prescribing,
    there is regular checking in with the Prescription Drug
    Monitoring Program, or our INSPECT program, upfront and then at
    regular intervals. There is drug testing, and docs have told us
    over and over and over again we need a way to prove whether or
    not they are taking the drugs or diverting the drugs. So drug
    testing is part of that. There is a daily threshold limit that
    if you go over 60 milligrams per day in the course of therapy,
    then you have to bring the patient back in for a face-to-face
    and consider referring them. And then there are contracts. And
    docs have told us those have been helpful too in terms of
    establishing the relationship, the expectations, and being able
    to fire a patient. The best man at my wedding got sued by
    someone who was using because they said he kicked them out of
    care and abandoned them. Contracts protect doctors moving
    forward in terms of being able to say I told you this, these
    will be the expectations, you violated them, and it empowers
    doctors to be able to participate. But we codified those into
    our rules and regulations, and it has been a tremendous
    success.
        Ms. DeGette. Thank you. I just want to talk for one second
    about treatment because I have heard that there is a shortage
    of doctors who can administer this MAT treatment, particularly
    in rural areas. So I just wanted to ask you, Mr. Stringer, very
    quickly to talk about Missouri. I understand Missouri requires
    all State behavioral organizations to offer MAT treatment to
    all patients with opioid disorders. Has this helped improve
    access for the patients?
        Mr. Stringer. Thank you, ma'am. It absolutely has improved
    access to evidence-based care. I will tell you that this has
    not been easy for our providers to find physicians. We had one
    in southwest Missouri who has since become one of our leading
    providers in medication-assisted treatment, but in the early
    days had to go through the Yellow Pages physician by physician
    to try to find one who was willing, number one, to work with
    this population, because many are not----
        Ms. DeGette. Yes.
        Mr. Stringer [continuing]. And then, secondly, who would
    work for the relatively low reimbursement rates that they could
    offer. So it was a real challenge, but absolutely, it has
    increased access to evidence-based treatment, but we still have
    these waiting lists.
        Ms. DeGette. Thank you. Thank you, Mr. Chairman.
        Mr. Murphy. Thank you.
        Mr. McKinley, recognized for 5 minutes.
        Mr. McKinley. Thank you, Mr. Chairman. Again, thank you for
    continuing this dialogue that we have now been doing for some
    time. We have had four or five hearings this year. Building off
    what we have learned in the past--a couple of years ago, we had
    a hearing in another committee where the Attorneys General had
    come in and talked about one of the things that they were
    suggesting on drug overdose and prescription--the pill mills,
    so to speak, whereas having a national registry in real time
    that was available to people across State lines as a way of
    capturing people that are trying to beat the system, is that
    something--I haven't heard any of you talk about the real-time
    entry data on that. Dr. Wolk, would you--I see you nodding on
    that, is that one of the things we should focus on?
        Dr. Wolk. Thanks, Representative McKinley. Yes, you know,
    we moved from periodic uploading to now daily uploading of the
    information, so it is real time with regard to our Colorado
    PDMP registry.
        Mr. McKinley. Yes, that is just in Colorado, but if they go
    across the State line, that is not available as well.
        Dr. Wolk. Right. I think we would be happy to morph our
    State PDMP into a national PDMP so that--especially for
    neighboring States, I think this is a significant challenge.
        Mr. McKinley. Thank you.
        Dr. Adams, your comment about overprescription--I would
    like to get some more--you started rattling off a lot of
    statistics and things that you do within Indiana to see how
    that works. I would like to see how we might be able to apply
    that in West Virginia as well and maybe across the country. So
    if that is not part of your testimony, if you have that
    separately, if you could send that, because we had this hearing
    just 3 weeks ago. We had seven panelists, and all of them said
    this is the number one priority, this is the number 1--and all
    of them were giving us different priorities. And I would like
    to think that Congress can walk and chew gum at the same time,
    but when we hear from professionals giving us all seven
    different directions, all seven agencies, so we asked them
    twhat is the number-one thing, and they talked about
    prescription.
        Dr. Adams. Um-hum.
        Mr. McKinley. They said we are overprescribing. So in the
    last 3 weeks, I have talked to a number of doctors at
    roundtables in West Virginia, and they are concerned--they
    agree, they say, yes, we are making addicts with what we do,
    but we have to have a development of trust with our patients.
    And do you--I get nervous about the fact that we want Congress
    to try to medicate or try to control--try to practice medicine
    on pain. So they are saying it is trust. How have you been able
    to rectify that or reconcile that in Indiana about dealing with
    that problem?
        Dr. Adams. Well, there is no doubt, and it is obvious from
    our outbreak, that we still have a lot of work to do. And I
    quickly want to touch on the point you brought up earlier. We
    could use a national registry for providers who divert on the
    job. That is the concern. Indiana was also the first State to
    have a Prescription Drug Monitoring Program talk across State
    lines. And it is still a problem. Scott County, Indiana, is
    just 20 minutes north of Louisville, but whether it is a
    national registry or just providing grants and funding to
    facilitate State PDMPs to adopt the best practices that talk
    across State lines, the consistent thing you heard all of us
    say is we need better communication, we need more real time
    information.
        As far as the trust factor, again, it is an uphill climb,
    but we have worked closely with our State medical association,
    and we got buy-in from doctors in terms of participating and
    other prescribers. And I think an important point my
    counterpoint brought up from Massachusetts was that it is not
    just docs, a lot of these are delegated prescribers, and the
    way you get around that problem is you have integration with
    electronic medical records.
        Mr. McKinley. So the more that--if you could get me that
    information----
        Dr. Adams. I would love to.
        Mr. McKinley. Then I want to open it up to all the panel. I
    am just curious, because you raised this issue last time, 3
    weeks ago, and that was that the rate of deaths in America from
    drug overdose is anywhere from 7 to 10 times higher than it is
    in Europe. I raised that question, and I raise it again: What
    are they doing right, or what are we doing wrong? Why from
    30,000 feet--what is the difference, why do we have such a
    problem in America compared to Europe?
        Dr. Adams. Again, pain as the fifth vital sign, and
    overflow of opioids going into the system, a lack of education
    for providers, and understanding on the part of children in the
    States.
        Mr. McKinley. So they are doing a better job in Europe, the
    medical community is doing a better job in Europe?
        Dr. Adams. I think they are. Less opioids available, in
    general, and I will yield to my counterpart from Massachusetts.
        Mr. McKinley. I am sorry, we are going to run out of time.
    So if you could get back to me, please, I would appreciate
    that. Thank you.
        Mr. Murphy. We will appreciate also the further elaboration
    on your point about when that becomes part of the hospital
    satisfaction survey, and then, of course, they get additional
    funding and that cycle, too.
        Now recognize the ranking member, Mr. Pallone, for 5
    minutes.
        Mr. Pallone. Thank you, Mr. Chairman.
        I want to mention, even before the opioid epidemic began,
    our infrastructure for treating substance abuse disorders in
    this country was shamefully inadequate, including cuts to our
    healthcare system through sequestration. A combination of long-
    term neglect, social stigma, and underinvestment by both the
    State and Federal Governments has led to a system in which only
    1 in 10 Americans with alcohol or drug addiction receive any
    form of treatment. And of those who receive treatment, only 10
    percent received evidence-based care. You combine this
    neglected behavioral health system with an epidemic of opioid
    overprescribing and it is really not surprising that we are
    currently facing a public health crisis.
        So questions. I would like to ask all the witnesses on the
    panel a question. Is our underinvestment in behavioral health
    services, including the effects of sequestration, hampering our
    response to the opioid epidemic? And let me combine that by
    saying, have you see the effects of sequestration affect what
    you are doing at the State level, and are you able to keep up
    with the increased demand for treatment with the current level
    of resources dedicated to the problem? I guess I will start
    with Dr. Adams and go down.
        Dr. Adams. Thank you for putting me on the spot,
    Representative. One thing that I have always held as my own
    personal adage is spending more is not the same as spending
    wisely. And so we will all come to you all and say we want more
    money, but the fact is what we are concentrating on, and
    something you have heard continually, is that we need to do a
    better job of communicating with each other to make sure we are
    making the most efficient and effective use of the funds that
    we have available. We need to make sure we are talking with
    communities, make sure we are talking with nonprofits, make
    sure that, through electronic medical records, we are getting
    the information that we need.
        Policy is always a pie that gets split up. And so do we
    have enough money, again, I would always love more money, but
    what I would love most from you all is help in terms of making
    sure the right partners are at the table so that we can get the
    most out what we are spending.
        Mr. Pallone. I mean--I appreciate what you are saying, but
    I am saying--my concern obviously is, first, sequestration, but
    even more so, you have more and more people that need
    treatment, and at best we are talking level funding. So, you
    know, if you could be a little more specific about the
    consequences of that, I would appreciate it. Not that I am
    taking away from what you said.
        Dr. Bharel?
        Dr. Bharel. So I want to go back to this point about this
    chronic disease model. So if we look at how we treat other
    diseases within the medical spectrum, when we talk about
    diabetes, there are multiple places to enter based on the level
    of severity. So you come into the emergency room, you go to an
    ICU, you go to a hospital, you go to outpatient. When you are
    suffering with the disease of addiction, there are very few
    routes to enter the system. So when we talk about different
    funding sources, I would like our goal to be to look at it as a
    complete health system.
        Getting back to this concept about Europe. If we think
    about health as a whole entity, and the public health starting
    at the community and going through the hospital system and out,
    we have to culturally think about not in our fast-paced
    thinking about pain being gone, but pain being relieved to a
    certain level, thinking culturally about pain not only being
    relieved with pills but other entities that are available as
    well, and then in addition to that, having PMP. Seventy-nine
    percent of our physicians in Massachusetts are on the PMP, but
    they say when we can't then use painkillers, what are other
    opportunities, so there are educational opportunities there as
    well.
        Mr. Pallone. All right. You guys don't want to--seem to
    want to talk about money.
        Voice. I do.
        Mr. Pallone. Let me add one more thing. Let me add one more
    thing. You know, SAMHSA, we understand that the SAMHSA Block
    Grant, or the Substance Abuse Prevention and Treatment Block
    Grant, you know, has actually been cut by 25 percent in the
    last 10 years. So, you know, maybe we want to talk about that
    if you don't want to talk about the other things. Go ahead.
        Dr. Wolk. Thank you, Representative Pallone. I will be
    quick because I know you want to say something about that.
        Absolutely, sequestration has had an impact. We cannot keep
    up with the demand, number one, so any additional resources
    that we can get through block grant money or however else we
    can do this would really be appreciated because even as a State
    ACA only goes so far with regard to coverages that folks can
    get adequate care. We received $65 million from the Federal
    Government for our innovation model, as Representative DeGette
    alluded to, so that patients coming to their primary care
    doctor can get integrated physical and behavioral healthcare
    services, including substance abuse screening, treatment
    services as well, because we are so desperate to try and
    address this access issue and this lack of resource issue that
    maybe there is something there with regard to where they get
    their primary care.
        Mr. Pallone. Thank you.
        Mr. Stringer. Mr. Chairman, I know we are out of time. If I
    could--I would like to follow up in writing if I can. That is a
    great question. I very much appreciate that. I was at a women's
    prison in Missouri in Vandalia just Tuesday of this week, and I
    have some stories to tell from that experience.
        Mr. Murphy. We would appreciate that. Thank you very much.
        Now recognize Dr. Bucshon for 5 minutes.
        Mr. Bucshon. Thank you, Mr. Chairman.
        And this has been very insightful, your testimony is very
    insightful.
        Dr. Bharel, I was interested in one of the things you said
    that 20 percent of the medication that people are abusing have
    been prescribed for medical reasons, and one of the things we
    have been focusing on, of course, is, you know, I am an
    physician, I was a cardiovascular surgeon before, is
    prescribing, you know, monitoring prescribing habits, but if 80
    percent is coming from somewhere else, where is it coming from?
    Seventy, 80 percent, whatever it is--I think you said 80
    percent.
        Dr. Bharel. Yes, it is 80 percent of what is--70 percent is
    coming from family and friends.
        Mr. Bucshon. OK, that is what I figured, so it is not their
    particular medical use, but at the end of the day, it has been
    prescribed for a medical use for someone. OK, and that is where
    maybe, you know, drop boxes and other initially voluntary
    return policies potentially could be helpful because--last
    year, you probably know, there were enough prescriptions
    written that every person in the United States of America could
    have gotten a bottle of narcotic pain medicine. And Medicare
    Part D just came out and said recently that the number one
    prescribed medicine under Medicare Part D--and so this goes
    across ages, right--was Vicodin.
        Dr. Bharel. Um-hum.
        Mr. Bucshon. And so I am very interested in the prescribing
    programs and trying to monitor, you know, physician
    prescribing, and as part of that, education is, of course,
    important. And that is where it is not only for the people
    using it, but it is the people that are being trained to take
    care of patients as we speak in medical schools and other
    areas. So that is going to be very important.
        Dr. Adams, in your testimony, you say an aggressive
    educational strategy beginning with childhood. Can you kind of
    expand a little bit on that, what your thoughts were on that?
        Dr. Adams. Well, thank you for the opportunity. And for
    those of you who don't know, Congressman Bucshon married up, he
    married an anesthesiologist.
        But as far as that----
        Mr. Bucshon. That is a true statement.
        Dr. Adams. The aggressive education campaign--quick story,
    I was in Scott County just a few weeks ago meeting with a 23-
    year-old individual who had HIV, he was in our clinic. And I
    said how did you get started, and he said, ``I had an injury as
    a freshman in high school, a knee injury playing football. The
    doc prescribed me Vicodin. I kind of liked how it made me feel
    so I took all the Vicodin he gave me, took some more, ran
    out.'' He said it was easy to get in the community. ``Got more
    Vicodin. Finally, that wasn't doing the job, switched to
    Oxycontin until that wasn't doing the job, then I started
    injecting.'' And then he switched over to heroin, and now he is
    a 23-year-old HIV addict.
        We have to get to these people earlier. And when you talk
    about an aggressive strategy, it starts with recognition. We
    need an educational campaign to help students understand that
    this is a problem.
        I used to sneak to my friend's house when I was in high
    school and have a beer. They sneak to their friend's house and
    pop a pill. And unfortunately, 1 out of 15 people who divert a
    pill will ultimately go onto heroin use. One out of 15 of my
    friends who popped a beer didn't go on to get HIV. So we need
    to increase the recognition of the problem. We need resilience
    in anti-bullying campaigns so that kids are OK saying no, I am
    not going to take a random pill out of that bowl. We need
    appropriate age level education, and I was meeting with people
    from the State just yesterday who showed us their data, and the
    interventions in each age group are different. What works for a
    fifth grader doesn't work for a sixth grader, doesn't work for
    an eighth grader. There has to be age-appropriate education and
    intervention. There has to be adult and peer outlets so, hey,
    if someone is doing something wrong, I know who to go to, I
    know who to tell. And then finally, to your point, we need
    take-back programs. Sixty-two percent of teenagers who use say
    they--number 1 reason they use is because it is easy to get the
    medication, it is from my parents' cabinet. It is right there.
    It is easier to get a pill than what it was for me to get a
    beer. And you can hide it and you can walk away with it. And so
    all that needs to be part of the campaign, and it needs to
    start in middle school and elementary school.
        Mr. Bucshon. I have one other question I want to ask about
    Naltrexone, because I have given that to patients in a hospital
    setting. And, Mr. Stringer, maybe you can comment on that, and
    I think not only the availability but the appropriate training
    for people, you know, for law enforcement people or EMTs about
    the fact that--like somebody pointed out, it is not a silver
    bullet here, there are also downsides to giving patients Narcan
    or Naltrexone. Can you comment on that, about what type of
    educational stuff is also--I mean--I think, were you one of the
    ones that were commenting on Naltrexone? Yes. Or maybe Dr.
    Bharel could answer that.
        Mr. Stringer. Maybe I can just----
        Mr. Bucshon. Yes.
        Mr. Stringer. I can start. And certainly, I will tell you,
    when I went to----
        Mr. Bucshon. And I am out of time, so can you--why don't we
    just do this----
        Ms. DeGette. Let----
        Mr. Bucshon [continuing]. Why don't you just----
        Ms. DeGette [continuing]. Dr. Bharel answer. She has been--
    --
        Mr. Bucshon. Why don't we----
        Mr. Murphy. Why don't we let Dr. Bharel answer?
        Mr. Bucshon. That will be fine.
        Dr. Bharel. So as part of our Narcan Program, so we have
    handed out in Massachusetts since 2007 over 35,000 doses of
    Narcan, and part of that includes to your point about
    education. So the individuals who are handing out the Narcan to
    both bystanders and law enforcement, there is a training that
    goes along with it, and they are also trained on rescue breaths
    and the importance of it being short-acting and to call 911 at
    the same time. And we have recorded over 5,000 reversals----
        Mr. Bucshon. Yes----
        Dr. Bharel [continuing]. With that. So the educational
    component is directly linked when we hand out our----
        Mr. Bucshon. Yes, I think that is important because, in my
    opinion, if someone has to give someone Narcan, they should
    also be calling 911, and those people probably should be
    transported to a medical facility.
        Thank you. I yield back.
        Mr. Murphy. We will want your other thoughts on it, too. We
    have all sorts of people saying that some people have a false
    sense of security thinking, oh, there is Narcan around, I can
    go ahead and take the risk.
        Mr. Tonko, you are recognized for 5 minutes.
        Mr. Tonko. Thank you, Mr. Chair.
        Mr. Stringer, earlier on in the questioning about
    sequestration you had some comments that we didn't get to.
    Perhaps you could share those right now please.
        Mr. Stringer. Yes, thank you very much, Representative. In
    my written testimony, there is a two-page thing from NASADAD
    here that describes the block grant and the reduced purchasing
    power of the block grant over time. I will tell you just
    specifically that I think with regard to sequestration. We in
    the States have really counted on the Federal Block Grant to
    sort of be our--really it is our safety net. We have some
    States have the safety net funds, but the block grant has
    always been stable. It hasn't grown enough to keep pace with
    inflation, but it has been stable. What we saw with the
    sequestration was that our sense of stability was shaken
    because we were during tough economic times at the State level,
    and then our block grant funds were reduced temporarily.
        Just this last Tuesday, I was visiting a women's program in
    Vandalia, Missouri, where we have a unique program going on
    right now where women offenders who leave that institution are
    started on medication-assisted treatment before they leave. So
    when they go home, they return to stable environments. Two of
    the women that I talked to had been on medications before they
    returned to prison. One was a young lady who was young,
    attractive, smart, had two children, was back in prison for her
    fourth DWI offense. Before coming to prison, she had been on
    medication-assisted treatment, but because of budget cuts at
    the State and Federal level, her medication-assisted treatment
    was stopped, and she returned to drinking very quickly after
    that, got her fourth DWI offense and then wound up back in
    prison.
        So, you know, the stability of the block grant, and I hope
    future increases in the block grant, will really help to sure-
    up our safety net, and increase access and sustainability of
    treatment.
        Mr. Tonko. I appreciate that. And for far too long our
    national infrastructure for treating substance use disorders
    has suffered from fragmentation, from neglect, and certain
    underinvestment. Only one in ten Americans with substance use
    disorders is able to access treatment, and of the few who
    receive treatment, few receive anything that approximates
    evidence-based care. Reimbursement is key to modernizing these
    services, and ensuring that Americans struggling with addiction
    receive timely, appropriate, and evidence-based care.
        The Affordable Care Act, mental health parity efforts go a
    long way toward accomplishing this, but requiring insurers to
    provide coverage for substance abuse treatment, but much more
    work remains.
        I know the States are experimenting with some innovative
    ideas. Dr. Wolk, can you provide us with an overview of
    Colorado's efforts to integrate behavioral health services into
    the primary care setting in the same Medicaid Program?
        Dr. Wolk. Thank you, Representative Tonko. Yes, and it is
    actually not just for Medicaid, we have a goal that all payers
    in the State will evolve with payment reform models that will
    allow integrated behavioral and medical care to be provided at
    the site of primary care. Our goal over the course of the next
    4 years is that 80 percent of all primary care practices in the
    State, whether they are federally qualified health centers,
    whether they are clinics, whether they are private practices,
    will all have some form of integrated behavioral healthcare as
    part of the primary care that is being provided as the
    patient's medical home.
        Mr. Tonko. And are there any Federal policy changes that
    you would suggest required in order for us to provide--ensure
    integration is indeed successful?
        Dr. Wolk. Thank you, Representative Tonko. There are along
    the lines, again, of really aligning the incentives to make
    sure that payers, for example, don't capitate or apportion
    behavioral health services and payment to a provider that is
    not part of this integrated model. It splits payment and,
    therefore, splits services. And so as a patient, you could come
    see your primary care provider, and that primary care provider
    would be prohibited from providing you mental health or
    substance abuse treatment services because the payer has
    allocated that money to a behavioral healthcare provider or
    substance abuse provider on a prepayment schedule, and that is
    where we could use some help with regard to reforming how those
    payments are made.
        Mr. Tonko. Um-hum. And, Dr. Bharel, just quickly, what do
    you view as the main barrier to integration of behavioral
    health and physical health?
        Dr. Bharel. So I think the main barrier is stigma, and that
    stigma is--penetrates throughout our entire system. My time is
    up so I will stop there. If I can say one more thing is that in
    Massachusetts, we too are looking towards outcome-based, value-
    based care throughout our system which includes the real
    cornerstone being primary care and behavioral health
    integration at the office level. We have multiple pilots going
    on including programs of prescribing Suboxone in our community
    health centers. Thank you.
        Mr. Tonko. Thank you.
        I yield back.
        Mr. Murphy. Thank you. Gentleman yields back.
        It is interesting the way deal with stigma straight on,
    integration. Good.
        Mr. Flores, you are recognized for 5 minutes.
        Mr. Flores. My questions have more to do with the education
    elements of that. The background for this is that I have three
    major educational institutions in my district--Baylor, Texas
    A&M University, and University of Texas--that are associated
    with medical schools. And so I would like to drill into going
    further upstream, and that is what can we do with the physician
    community and the expert community, professional community, to
    help them to be able to deal with this better?
        So my first question is this, and this is for each of you.
    Should all physicians be required to complete a continuing
    medical education course on pain treatment, and if so, should
    they also be mandated to complete one on addiction? And I will
    just start with you, Mr. Adams.
        Dr. Adams. Should all physicians? I would change that to
    say all prescribers----
        Mr. Flores. OK.
        Dr. Adams [continuing]. Because it is not just physicians
    prescribing, and not all physicians prescribe opioids. But we
    have had tremendous success, again, in Indiana. Once we
    instituted the opioid prescribing rules, then that led to an
    educational campaign where we had the opportunity and created
    the passion for these docs, and they had to carve out the time
    these docs and other providers to learn about the proper ways
    to prescribe.
        Mr. Flores. OK. Dr. Bharel, your thoughts?
        Dr. Bharel. So we also have all physicians required to do
    pain management training, but to your point, I would say that
    most medical schools, PA schools, nurse practitioner schools,
    et cetera, other practitioners who prescribe, do not have
    acquired training on addiction or its variable in school.
        Mr. Flores. OK.
        Dr. Bharel. So going further upstream at a Federal level,
    these accreditation bodies could be looked at to require some
    of that training.
        Mr. Flores. OK. Dr. Wolk?
        Dr. Wolk. Thank you, Representative Flores. In Colorado,
    some of this training is tied to malpractice premium reduction,
    and so a way around us making a requirement is, you can save
    some money on your malpractice insurance if you take this
    training. And as we said, don't forget about the dentists, the
    nursing community, the optometrists, and the podiatrists
    because they are all prescribers, to the point that was made
    before.
        Mr. Flores. OK. Go ahead, Mr. Stringer.
        Mr. Stringer. And my answer to your question is
    unequivocally yes, there should be mandatory education.
        Mr. Flores. Right. So the next question would be, and this
    is again for all of you: Does your State think there is any
    merit to linking mandatory physician education for PDMPs to DEA
    licensure as a way to promote physician use of PDMPs when
    prescribing a controlled substance? Dr. Adams?
        Dr. Adams. I have been longwinded before so I will be very
    brief. Yes.
        Mr. Flores. OK. Dr. Bharel?
        Dr. Bharel. We already require, at the time of license
    renewal, for all physicians to sign onto PDMP----
        Mr. Flores. I see.
        Dr. Bharel [continuing]. And that is how we have
    increased----
        Mr. Flores. The question is yes on the merit?
        Dr. Bharel. Yes.
        Mr. Flores. OK, great. OK. Perfect.
        Dr. Wolk. Yes, we already require.
        Mr. Flores. OK. Mr. Stringer?
        Mr. Stringer. Sadly, I can only speak theoretically or
    hypothetically since Missouri is the only State in the country
    that does not have a PDMP yet, although it came very close this
    session, but----
        Mr. Flores. OK.
        Mr. Stringer [continuing]. So I would say yes.
    Theoretically, yes.
        Mr. Flores. OK. Theoretically. I understand. Again, for
    each of you, and we have just a minute and 45 left. What are
    the opportunities to--or let me rephrase that. What are the
    opportunities to improve the education of physicians on the
    appropriate prescribing of prescription pain medication? Is it
    medical school, continuing education, all the above, or
    somewhere else?
        Dr. Adams. It is both. I am an assistant professor at the
    medical school, and we don't get it in medical school, but then
    there are docs out there who are prescribing or want to
    prescribe who don't have that education. And I am sorry to keep
    bringing it back, but in many cases, the majority of people
    doing the prescribing of opioids are not physicians. So you can
    do all you want with docs, but if you aren't taking care of
    everyone who is prescribing opioids, you are not going to solve
    the problem.
        Mr. Flores. OK.
        Dr. Bharel. I would say all prescribers at all levels, but
    also to bring back to the point that we all have to be
    educated. So it is a cultural shift also to our expectations of
    pain relief.
        Mr. Flores. OK. Dr. Wolk?
        Dr. Wolk. I believe it is ongoing, but again, think about
    tying it to their wallet and then their malpractice premiums.
        Mr. Flores. Uh-huh, OK. Mr. Stringer?
        Mr. Stringer. All the above.
        Mr. Flores. And the last question is this. And I have just
    a comment. Dr. Bharel, you said something about a cultural
    shift. Is this going to be hard to implement if we began
    pressing all of the prescribers to have continuing education,
    and then further upstream, to have the medical schools or the
    professional schools mandate this as part of their training? Do
    you see pushback in this?
        Dr. Bharel. It is mandated right now in Massachusetts, and
    I believe the prescribers really want to be part of the
    solution, so they are looking to work together. So I think that
    will be the driving force. They are also fed up with the
    numbers and the statistics.
        Mr. Flores. Um-hum.
        Dr. Adams. You will see pushback, but it is something that
    we have to do. And again, as Dr. Bharel mentioned, docs want
    it, but we need to facilitate them getting the education, and
    needing to carve out the time either via tying it to the wallet
    or tying it to certification.
        Mr. Flores. OK, thank you. I yield back the balance of my
    time.
        Mr. Murphy. Gentleman yields back.
        Now recognize the gentlelady from New York, Ms. Clarke, for
    5 minutes.
        Ms. Clarke. I thank you, Mr. Chairman, and I thank our
    ranking member. I also thank our witnesses for lending your
    expertise through your testimony here today.
        I would like to ask about the impact of Medicaid expansion
    on increasing access to treatment for substance abuse
    disorders. According to the Centers for Medicare and Medicaid
    Services, an additional 11.7 million individuals were enrolled
    in Medicaid and CHIP programs since the initial marketplace
    enrollment began in October of 2013, however, 21 States have
    failed to adopt the Medicaid expansion, leaving large coverage
    gaps for adults whose incomes are too high to qualify for
    Medicaid, but too low to qualify for premium tax credits
    through the exchanges.
        Let me start, Dr. Adams, by asking, has Medicaid expansion
    affected access to behavioral health services in the State of
    Indiana?
        Dr. Adams. Well, the answer is yes, but I want to correct a
    term you used. In Indiana, we didn't expand Medicaid, we
    received a waiver to reform our Medicaid program via the
    Medicaid expansion funds. And I think that is a key here that
    we need to allow States to come up with----
        Ms. Clarke. No, I----
        Dr. Adams [continuing]. The best possible policy.
        Ms. Clarke. That wasn't my point.
        Dr. Adams. Yes.
        Ms. Clarke. It was just a question.
        Dr. Adams. Yes, ma'am.
        Ms. Clarke. Has expansion impacted your ability to address
    the HIV outbreak in Scott County?
        Dr. Adams. Expansion via the Healthy Indiana Plan has
    substantially increased our ability. We signed up over 300
    people for health coverage as part of this outbreak into our
    Healthy Indiana Plan.
        Ms. Clarke. Well, I thank you for your illuminating
    response. I hope that other States recognize the impact that
    Medicaid expansion can have on their ability to diagnose and
    treat substance abuse disorders, and comorbidities such as
    mental illness, HIV, and Hepatitis C.
        Mr. Stringer, I would like to turn to you. The current
    limit for nondisabled adults to qualify for Missouri's existing
    Medicaid program, MO HealthNet, is 18 percent of the poverty
    level, or $2,118 a year. Missouri is a State that has not
    expanded Medicaid, resulting in a large coverage gap of adults
    whose incomes are between 18 and 100 percent of the Federal
    poverty level. Mr. Stringer, approximately 300,000 working
    adults would gain access to health coverage through Medicaid
    expansion, is that correct?
        Mr. Stringer. Yes, that is correct.
        Ms. Clarke. How would Medicaid expansion affect the
    population you serve in Missouri?
        Mr. Stringer. Well, ma'am, of those 300,000, we estimate
    that about 50,000 are people with some type of mental illness
    or substance use disorder that have no coverage at all right
    now.
        Ms. Clarke. Um-hum.
        Mr. Stringer. And so we are right now, for those that are
    in our system, we are paying for those with 100 percent general
    funds or block grant funds. If and when we expand Medicaid in
    Missouri, those people will receive Medicaid coverage, which
    does cover substance use disorder treatment in Missouri, and
    that would, therefore, free-up those funds to treat people who
    remain uninsured for whatever reasons, to provide other kinds
    of services to help people get back to work, things like that.
    So it would have a tremendous impact on Missouri.
        Ms. Clarke. Wonderful. I thank you for your perspectives.
        And I yield back the balance of my time. Thank you.
        Mr. Murphy. Gentlelady yields back.
        Now recognize Mrs. Brooks for 5 minutes.
        Mrs. Brooks. Thank you, Mr. Chairman.
        Dr. Adams, you recently wrote an op-ed, and your quote was
    that building a model for prevention and response should this
    type of outbreak happen in other communities in the U.S. Can
    you talk to us a little bit, and kind of trying to bring it
    back a bit to the HIV outbreak in Scott County, can you explain
    for us what the model looks like? When you talk about the
    model, what model are you referring to?
        Dr. Adams. Thank you for the opportunity. And the Governor
    and I sat down at the beginning of this and said we are going
    to make mistakes, but we want this to be a model moving
    forward. And one important part of that was a comprehensive
    program. The HIV spills over into the opioid epidemic, spills
    over into Hepatitis, et cetera. And at our community outreach
    center in Scott County, we wanted to make sure people were able
    to access a multitude of services that are constant barriers to
    them getting into the treatment that they need. At our
    community outreach center, we had over 789 visitors, 271 HIV
    tests, 302 people enrolled in the Healthy Indiana Plan, 87
    mental health referrals, and 38 job referrals. And we also
    offer birth certificates and identification, which is a barrier
    for people signing up for insurance. And importantly,
    immunizations for Hepatitis A, Hepatitis B, and the Tdap. When
    you include the needle exchange into that, I would venture to
    say you won't find another place in our country that offers all
    those services under one small roof.
        Now, what we need to do is look at that as a success, and
    in terms of responding to an epidemic in the future, other
    places should consider providing all those comprehensive
    services, but for the long-term, we need to make sure within
    communities we are not just providing one part, that we are
    providing the comprehensive services people need because,
    again, this is a vulnerable population. OK, here is health
    insurance. Well, I don't have an ID to sign up for it. I can't
    prove I am a citizen. Well, here is access to HIV care. But I
    don't have transportation or it is not available. Well, there
    is an opportunity for you to get into a treatment center. But
    the people aren't here, they are not close by. So when I say a
    comprehensive response and a model response, it is including
    all those services and thinking about overcoming barriers for
    the people we are trying to reach.
        Mrs. Brooks. Thank you very much. And best of luck as you
    continue to lead the efforts on behalf of the State.
        I want to shift very briefly in the time I have left to
    discussion about the criminal justice system. And in a previous
    hearing we talked about drug treatment courts, and obviously
    the State also has a tremendous responsibility for the
    corrections system, and the corrections systems are
    administered by the State. And so I would be interested in any
    of your comments with respect to what your States are doing
    with respect to opioid abuse in our corrections systems, and/or
    the coordination with the drug treatment courts. I know that is
    a big question, but yet I think that is a group of folks who
    are incarcerated or who are on their way to incarceration
    through drug treatment courts, and I am really curious what
    your thoughts have been in your States.
        Dr. Adams. Briefly, in our district, we have had much
    success with Vivitrol and drug courts and diversion programs,
    and we have actually connected the prosecutors from Hamilton
    County, which is in our district, with the people from Scott
    County to share best practices. And I think that is going to be
    a critical, critical aspect moving forward to empowering people
    when they are, quite frankly, a captive audience.
        Mrs. Brooks. Thank you. Dr. Wolk or Mr. Stringer?
        Mr. Stringer. Well, I talked earlier about a project we
    have going on in Missouri within our Department of Corrections
    where people are started on medications before they leave
    prison. That is happening in several of our institutions right
    now, as well as the St. Louis City Jail, before people go into
    drug court. So we are starting people on medications before
    they leave incarceration. We also have a growing number of drug
    courts in Missouri, all of whom have embraced medication-
    assisted treatment. In fact, the drug court contracts in
    Missouri require that drug courts offer medication-assisted
    treatment for people for whom it is appropriate.
        Mrs. Brooks. Dr. Wolk, anything with respect to Colorado's
    approach?
        Dr. Wolk. Thank you, Representative Brooks. It varies by
    where the population is most dense. So we have a very active
    program in the Denver metropolitan area. A variety of treatment
    options and transition programs from corrections back into the
    community as well. It is not as easy to take advantage of those
    in the more rural parts of our State.
        Mrs. Brooks. Thank you. Dr. Bharel?
        Dr. Bharel. And in Massachusetts, we have a strong support
    for drug courts, diversion programs, and starting medication-
    assisted therapy, and part of our working group includes law
    enforcement and multiple segments of the community. And in
    addition, we have several pilots going on where before release,
    individuals are connected to community health centers so that
    their continuity of care can happen in both behavioral and
    medical illness.
        Mrs. Brooks. Thank you all for your work.
        I yield back.
        Mr. Murphy. Mr. Green, you are recognized for 5 minutes.
        Mr. Green. Thank you, Mr. Chairman.
        I would like to focus question on the overprescribing of
    opioid pain relievers, and what States are doing to prevent the
    opioid addiction in the first place. CDC Director Tom Frieden
    quotes, ``Overdose rates are higher where opioid painkillers
    are prescribed more frequently. States with practices where
    prescribing rates are highest need to take a particularly hard
    look at ways to reduce the inappropriate prescription of these
    dangerous drugs.'' As this quote says, the States where the
    rubber really meets the road in terms of prevention efforts and
    addressing the overprescribing of opioid.
        Dr. Adams, I know Indiana has been hit hard by the opioid
    abuse epidemic. Can you tell us what the mandatory prescription
    guidelines that the Indiana Medical Licensing Board develops,
    and not just the Medical Licensing Board, if you could talk
    about all the practitioners: the nurses and dentists that have
    the same--hopefully their prescribing requirements are on all
    the specialties.
        Dr. Adams. Thank you for the opportunity. And we passed
    those rules and the Medical Licensing Board passed them
    initially for physicians, and now the other Boards are adopting
    their own versions of the rules. But again, a critical part of
    that was the mandatory checking in and being a part of the
    INSPECT, the Prescription Drug Monitoring Program. A mandatory
    part was assessment and H&P and regular visits. You have to
    have a face-to-face and a relationship with a patient before
    you prescribe. A mandatory part of that is drug testing so we
    can know what you are taking, and if you are taking it
    appropriately. And as many people will take more, there are
    frequently people who are diverting.
        Mr. Green. Um-hum.
        Dr. Adams. And we found that problem in Scott County.
    Again, a lot of the prescriptions are to little old ladies who
    really do have chronic pain issues, but they can resell their
    pills for $500, $1,000, and quite frankly, put diapers on their
    grandchildren, versus properly use those opioids. So we need to
    be able to drug test people who we are giving opioids to, and
    we need to have contracts. Again, the docs have told me that
    they are scared to write, and then the docs that are writing
    are scared not to write because you can get sued either way.
    And so we need to be able to protect docs and their ability to
    do the right thing.
        Mr. Green. OK. Do you believe efforts are making an impact
    on inappropriate prescribing of the opioid medications? I know
    you said the other specialties, but at least on the Medical
    Board that you may have some evidence on.
        Dr. Adams. Well, exactly. We have seen drops of 10 percent
    in prescribing since we adopted the rules. We have a lot fewer
    pill mills, and that is really what was the impetus for this,
    but we have to do a better job with our Prescription Drug
    Monitoring Programs. Best practices need to be adopted, and the
    ability to communicate across State lines however we facilitate
    that, because we can't do anything if we don't know the
    numbers, and we can't do anything if we know the numbers but we
    can't share the data with the appropriate prescribers.
        Mr. Green. What should we be doing on the Federal level to
    support your efforts of implementing effective interventions to
    prevent opioid abuse?
        Dr. Adams. Well, Senator Donnelly and Senator Ayotte have a
    bipartisan bill that they are promoting right now that has a
    lot of good ideas in it, and I would encourage you all to look
    at that rather than me spend time going through each of the
    points.
        Mr. Green. Um-hum.
        Dr. Adams. The Heroin and Prescription Opioid Abuse
    Prevention, Education, and Enforcement Act of 2015. I think it
    has a lot of the right ingredients in terms of taskforces and
    highlighting the areas that we need to concentrate on.
        Mr. Green. OK. Dr. Wolk, can you tell us about some of the
    same in Colorado, the opioid prescribing guidelines developed
    by the State Boards, again, whether it is medicine, pharmacy,
    nursing, or dentistry?
        Dr. Wolk. Thank you, Representative Green. Yes, it really
    just keeps coming back from the provider perspective to the two
    main points, or the two number one priorities; one is the
    mandatory participation in PDMP registration, and the second is
    some form of requiring or strongly encouraged training with
    widespread adoption across all the disciplines, because we have
    seen, like I said, 87 percent of those who participate in the
    training said that they would change their practice as a result
    of it.
        Mr. Green. OK. I only have a few seconds. One of the issues
    is doctor-shopping, and is there anything technologically we
    can do to deal with that?
        Dr. Wolk. Yes----
        Mr. Green. And this would be for all of----
        Dr. Wolk. Sure. We have had a lot of success with the use
    of our health information exchange and having broad
    participation by all of our hospital systems in the State of
    Colorado, and now well over 1,000 providers who have connected
    their electronic health records to each other so that when
    somebody comes into an office or an emergency room, it is
    relatively easy to now see who they have seen and what they
    have been prescribed or provided for.
        Mr. Green. Mr. Chairman, in my last second, Dr. Bharel, you
    talked a lot about Federal qualified health centers and the
    community centers. In Massachusetts, do they have access to
    that same medical record across the lines of the different
    centers?
        Dr. Bharel. Yes, sir, there are many different integrated
    health records that we are looking at. And the PMP is really
    adding to this because it is system-wide, any prescription
    written within Massachusetts, or written out of Massachusetts
    for somebody residing in Massachusetts. What we really do need
    though is interoperability that is better between States and
    also between different EHRs, so we can then expand our view.
        Mr. Green. OK, thank you. Thank you, Mr. Chairman.
        Mr. Murphy. Thank you.
        Gentleman from Oklahoma, Mr. Mullin, is recognized for 5
    minutes.
        Mr. Mullin. Thank you, Mr. Chairman, and thank you for
    being persistent on getting down to the roots of the problem. I
    mean this is obviously an epidemic, and I would say most of us
    know somebody that has abused prescription drugs at one time or
    the next. You know, recently I just went through a surgery on
    my elbow and got prescribed a big old pill of pain medicine,
    and I wouldn't even take one of them. Fortunately, I have had a
    lot of surgeries, or unfortunately, and I have built up some
    type of a pain tolerance, but it does become a habit. The pain
    is still there, it just masks it. And when you get used to it,
    it becomes a dependency. And what we are seeing is--in my
    opinion, it is severely being overprescribed. And, Dr. Bharel,
    you are aware of the severe rise in methadone prescriptions, I
    am assuming, right? The rise in it, how often it is being----
        Dr. Bharel. The rise in methadone, yes. Yes.
        Mr. Mullin. Right. Are you aware that methadone accounts
    for 30 percent of overdose deaths, while only----
        Dr. Bharel. Um-hum.
        Mr. Mullin [continuing]. Basically covering 2 percent of
    the prescriptions?
        Dr. Bharel. Yes.
        Mr. Mullin. Then I guess the question is why does
    Massachusetts leave it as a preferred list as a drug to be
    prescribed when CDC is saying it shouldn't be the first line,
    it should be considered just in a case-by-case situation,
    rather than being prescribed on a regular basis?
        Dr. Bharel. Thanks for your question. So methadone, you
    know, has become a part of the armamentarium of what can be
    used as pain relievers. In looking at our data within
    Massachusetts, and the data that we collect at the Department
    of Public Health, when we collect preferred drug of choice
    first and second, methadone is actually lower than the average
    in Massachusetts. It is less than 15 percent as the preferred
    drug of choice. But just like with all the other medications,
    there needs to be education around how to use methadone if it
    is going to be used for pain or not. So I agree with that
    point.
        You brought up a point earlier about many people knowing
    somebody who has used or abused opioids, and I want to bring up
    a point. There was a recent study done through the Harvard
    School of Public Health----
        Mr. Mullin. Um-hum.
        Dr. Bharel [continuing]. Where they looked at the majority
    of us knows somebody who has struggled with addiction, and of
    those who have, 20 percent of us know somebody who has died
    from it. So it is really a profound problem, to your point. And
    one very interesting thing related to this question that you
    are asking is that 36 percent of individuals who were
    prescribed an opiate were not made aware or did not know about
    the addiction potential. So I think that needs to be part of
    the education.
        Mr. Mullin. And I agree with that, but then if we know that
    and it is so readily accessible, still yet I am concerned why
    Massachusetts and Indiana, Dr. Adams, would still leave it on
    your list of prescribed medications, I mean when CDC and
    American Academy of Pain Medicine both have said that methadone
    should not be considered a drug of first choice. But when it is
    listed, we all know that doctors refer to this constantly. In
    fact, that is where Medicaid and Medicare a lot of times gets
    the prescriptions or the drugs that they are able to prescribe
    from.
        Dr. Adams. It is cheap.
        Mr. Mullin. Well, so--I know, but--so a person's life is
    cheap?
        Dr. Adams. Well, no, a person's life is not cheap, and I
    appreciate that question. Again, as a person who has been
    trained in pain management, methadone is a great drug when used
    appropriately.
        Dr. Bharel. Um-hum.
        Dr. Adams. So the problem is that the prescribers aren't
    educated and aren't using it appropriately. So you have a
    policy situation where you have a cheap drug that the doctors
    know can be used appropriately, but a real world situation
    where it is not being used appropriately.
        Mr. Mullin. Dr. Adams, I really appreciate your bluntness,
    but cheap shouldn't matter when we are talking about someone's
    life. We know it is being abused. History says it is being
    abused.
        Dr. Adams. Um-hum.
        Mr. Mullin. So why is it still there?
        Dr. Adams. Well, because, again, from a policy point of
    view, there are two different directions you can take this. You
    can either say take it off the formulary and what are we going
    to replace it with----
        Mr. Mullin. Education isn't working. We all get those
    little bottles with the little label on it, and then it even
    has a folded-up package. And I am sure everybody in this room
    has always read that folded-up package.
        Dr. Adams. Um-hum.
        Mr. Mullin. And all of us know what the side-effects are
    and what the consequences are of everything that we have ever
    taken, and in fact, if you are one of those people, I am not--
    --
        Dr. Adams. And as a State health commissioner, I will tell
    you you are right, and again, I will be blunt and say you are
    right. There is a problem and we need to figure out the best
    way to address the problem, while still providing pain
    management options for the people who are out there.
        Mr. Mullin. So, Dr. Adams and Dr. Bharel, while we are
    figuring it out, do you still think it is a good idea to have
    it on your Web site as a preferred medication?
        Dr. Adams. That is a great question, and again, the blunt
    answer is, that is a different division than my division. I
    have spoken with Dr. Werner about this problem, and docs feel
    passionately on both sides of the issue, but it is at the top
    of our radar in terms of making sure we are educating people
    and considering all options.
        Mr. Mullin. Dr. Bharel, you want to follow up on that?
        Mr. Murphy. Gentleman's time has expired. You can do it
    real quickly. We are about to have votes, so I want to move.
        Dr. Bharel. I think this issue is going to be a
    multipronged approach, and one of them is looking carefully at
    the medications we prescribe, and making sure that individuals
    are educated on how to best describe them. Thank you for your
    question.
        Mr. Mullin. Mr. Chairman, thank you.
        Mr. Murphy. Thank you.
        I recognize now Dr. Burgess for 5 minutes.
        Mr. Burgess. Thank you, Mr. Chairman. And I must say, every
    time I listen to the gentleman from Oklahoma, I learn
    something. And it is a hazard in relying on a medical education
    that is over 40 years old, but I remember the morning in
    medical school hearing the lecture on methadone, and it was
    repeated over and over again; methadone is for maintenance
    purposes only. I mean I will never forget the guy saying that.
    But is that no longer true; methadone now is being used for
    things other than maintenance? Dr. Adams.
        Dr. Adams. In terms of maintenance for medication-assisted
    treatment, or you mean for chronic pain?
        Mr. Burgess. Well, for someone who has an opiate
    habituation.
        Dr. Adams. Well, the answer is that there are a lot of
    prescribers out there who don't have the proper education to be
    prescribing the drugs that they are prescribing, and it is a
    problem. It is----
        Mr. Burgess. But again, 40-year-old wisdom, you have
    somebody who has a narcotics habit, they want to rehabilitate
    themselves, they want to get back to taking care of their
    family, back into society, they can be maintained on methadone
    and allowed to function because it didn't have the other
    effects that other opiates do, so they can get the high, but
    they solve the problem of the addiction, at least temporarily.
    But now methadone has uses beyond that?
        Dr. Adams. Well, OK, so I am glad you brought that up.
    Again, there is a lot of misunderstanding about methadone.
    There is methadone as used for chronic pain, which the
    gentleman from Oklahoma was talking about, and then there is
    methadone for medication-assisted treatment, which is the
    person who has substance use disorder who is using it to
    continue functioning. And those are two very different uses of
    methadone, and confusion has led to a lot of policy decisions
    that I think are underinformed. It is important to know that
    methadone can be a substantial and important part of people's
    recovery if they are suffering from substance use disorder, but
    it is also important, to the point of the gentleman from
    Oklahoma, that we recognize and deal with the real problem of
    methadone being prescribed for chronic pain inappropriately,
    because it is killing people. I completely agree with you, and
    I thank you for bringing up that point, sir.
        Mr. Burgess. All right, I am going to switch gears because
    I had a couple of questions about Naloxone. And I have some
    other questions about NASPER, but then I will probably have to
    submit for written responses because of time. But we have had a
    number of these hearings, and I have expressed support for
    having compounds like Naloxone or Narcan available over the
    counter. I mean, let's be honest: People need it, they need it
    right now, they don't need to be going to get a prescription.
    So just this week the FDA announced a public meeting to discuss
    increasing the use of Naloxone. Now, Dr. Bharel, in
    Massachusetts, your State has been kind of an early adopter in
    this area. Can you share some of that experience with us?
        Dr. Bharel. Sure. So as I mentioned earlier, we have been
    using Narcan treatments since 2007. We first started by doing
    outreach to high-risk individuals who were using injection
    drugs as part of an, actually, HIV prevention, treatment
    education program, and since then from there moved on to work
    with so-called bystanders, which hare family and friends. And
    we use our existing community coalitions, such as our learn-to-
    cope, family-run coalitions throughout the State in order to
    have them provide Narcan. And this is done through standing
    medical orders, so it is still not an over-the-counter, it is
    through standing medical orders, as well as certain pharmacies
    participate in having it available through standing medical
    orders. And then finally, through the first responders program;
    both fire and police, in dozens of communities across
    Massachusetts have adopted the program as well.
        Mr. Burgess. And, Dr. Adams, can you share with us some of
    your experience in Indiana?
        Dr. Adams. Well, we have had great success, some wonderful
    stories, but I want to second a point that Dr. Bharel made
    earlier that it is important not just to hand out Naloxone, but
    to provide education as part of that process. There is a big
    fear--and I think Representative Murphy brought this up
    earlier, Chairman Murphy--that if you are giving people this,
    they will then use it as an excuse to abuse. That has been
    proven not to be the case when you combine the passing out of
    Naloxone with education. So when you are considering policies
    moving forward, please don't forget the educational component
    because that is what saves lives, along with the Naloxone.
        Mr. Burgess. Yes, of course, that could be said about so
    many other things that we sometimes get involved in, but I
    appreciate your answers.
        Mr. Chairman, I am going to yield back the time because I
    know votes are coming.
        Mr. Murphy. All right, I want to thank all of the members
    who were here for this, and this panel. This has been a
    fascinating process. We know what will come out of this. We
    will get our staffs together. You gave us a great set of
    recommendations today, thank you.
        We do ask you to follow up on some of those other
    questions, and please feel free, if you have other thoughts
    that come from this, it is the kind of things you are thinking
    about on the plane ride back or when you get back to your
    colleagues. We want to see what we need to do in terms of
    drafting legislation, working with the administration on
    regulatory changes, working with associations on some of these
    issues. This is critically important. Too many people have
    died, even during the course of this hearing today. I know you
    all care deeply about this. We share that caring, and we want
    to see this change. So thank you very much.
        So I want to thank all the witnesses and members again for
    being here, and remind members that they have 10 business days
    to submit their questions to record. And we ask that you
    respond promptly to that.
        And with this, this committee hearing is adjourned.
        [Whereupon, at 12:05 p.m., the subcommittee was adjourned.]
        [Material submitted for inclusion in the record follows:]

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