[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.]
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