[Senate Hearing 114-852]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 114-852

                  FIGHTING AGAINST A GROWING EPIDEMIC:
                        OPIOID MISUSE AND ABUSE
                         AMONG OLDER AMERICANS

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

                                HEARING

                               BEFORE THE

                       SPECIAL COMMITTEE ON AGING

                          UNITED STATES SENATE

                    ONE HUNDRED FOURTEENTH CONGRESS


                             SECOND SESSION
                               __________

                           LEESBURG, VIRGINIA
                               __________

                            FEBRUARY 1, 2016
                               __________

                           Serial No. 114-18

         Printed for the use of the Special Committee on Aging
         
         
                  [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]         
         
         
        Available via the World Wide Web: http://www.govinfo.gov
        
                              ___________

                    U.S. GOVERNMENT PUBLISHING OFFICE
                    
48-286 PDF                WASHINGTON : 2022          
        
        
        
                       
                       SPECIAL COMMITTEE ON AGING

                   SUSAN M. COLLINS, Maine, Chairman

ORRIN G. HATCH, Utah                 CLAIRE McCASKILL, Missouri
MARK KIRK, Illinois                  BILL NELSON, Florida
JEFF FLAKE, Arizona                  ROBERT P. CASEY, JR., Pennsylvania
TIM SCOTT, South Carolina            SHELDON WHITEHOUSE, Rhode Island
BOB CORKER, Tennessee                KIRSTEN E. GILLIBRAND, New York
DEAN HELLER, Nevada                  RICHARD BLUMENTHAL, Connecticut
TOM COTTON, Arkansas                 JOE DONNELLY, Indiana
DAVID PERDUE, Georgia                ELIZABETH WARREN, Massachusetts
THOM TILLIS, North Carolina          TIM KAINE, Virginia
BEN SASSE, Nebraska
                              ----------                              
               Priscilla Hanley, Majority Staff Director
                 Derron Parks, Minority Staff Director


                         C  O  N  T  E  N  T  S

                              ----------                              

                                                                   Page

Opening Statement of Senator Tim Kaine, Member of the Committee..     1

                           PANEL OF WITNESSES

Mark Herring, Attorney General, Commonwealth of Virginia.........     8
Jane Terry, Director of Government Affairs, National Safety 
  Council........................................................    10
Katherine Neuhausen, M.D., M.P.H., Assistant Professor, 
  Department of Family Medicine and Population Health, and 
  Associate Director, Office of Health Innovation, Virginia 
  Commonwealth University........................................    12
Lisa Wilkins, Acting State Director, Virginia Change Addiction 
  Now............................................................    15
Mellie Randall, Director, Office of Substance Abuse Services, 
  Virginia Department of Behavioral Health and Developmental 
  Services.......................................................    18

                                APPENDIX
                      Prepared Witness Statements

Mark Herring, Attorney General, Commonwealth of Virginia.........    43
Jane Terry, Director of Government Affairs, National Safety 
  Council........................................................    48
Katherine Neuhausen, M.D., M.P.H., Assistant Professor, 
  Department of Family Medicine and Population Health, and 
  Associate Director, Office of Health Innovation, Virginia 
  Commonwealth University........................................    54
Lisa Wilkins, Acting State Director, Virginia Change Addiction 
  Now............................................................    64
Mellie Randall, Director, Office of Substance Abuse Services, 
  Virginia Department of Behavioral Health and Developmental 
  Services.......................................................    70

 
                  FIGHTING AGAINST A GROWING EPIDEMIC:
                      OPIOID MISUSE AND ABUSE
                       AMONG OLDER AMERICANS

                              ----------                              


                        MONDAY, FEBRUARY 1, 2016

                                       U.S. Senate,
                                Special Committee on Aging,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 10:34 a.m., in 
the Loudoun County Government Center, 1 Harrison Street, S.E., 
Leesburg, Virginia, Hon. Tim Kaine, Member of the Committee, 
presiding.
    Present: Senator Kaine.
    Ms. Phyllis Randall. [Speaking off microphone.]--so this 
issue for me has been close to my heart for many years... 
[inaudible] great opportunity in speaking about it right now. I 
welcome you all to Loudoun County for such an important issue, 
such an important event, and I want to first acknowledge some 
people in the room. Of course, our Attorney General, Loudoun's 
own Mark Herring is with us... [inaudible] Kristen Umstattd, 
Supervisor from the Leesburg District, and the acting Mayor of 
Leesburg, Kelly Burk, has joined us.
    Next, we have people from the County's Area Agency on 
Aging. If you are here, would you raise your hand. Look at 
that. Thank you for coming... [inaudible] this issue is such an 
important issue. Opiate abuse or substance abuse in general is 
something that really has affected our country, our 
Commonwealth, and our county, and there are different 
demographic... [inaudible] it hits in different ways, and we 
often do not think about how it actually affects the 65-and-
over population, and it does affect it in so many different 
ways, so without further adieu, I welcome to the county and 
welcome Senator Tim Kaine.

                 OPENING STATEMENT OF SENATOR 
               TIM KAINE, MEMBER OF THE COMMITTEE

    Senator Kaine. Well, good morning, and thank you all for 
being with us today.
    Let me do the official business and first bring to order a 
meeting of the Senate Special Committee on Aging. This is a 
field hearing of the Aging Committee and the title of the 
presentation, as you know, is ``Fighting Against a Growing 
Epidemic: Opioid Misuse and Abuse Among Older Americans.''
    I am very happy to be back in Leesburg, back in Loudoun 
County. This is a committee I have been on for about a year and 
they like to do field hearings and get out among the community 
and I have been looking forward to this, and I appreciate 
everybody who was planning to come last Monday who we all 
decided that it would be better to come today, and how good to 
come, and there is still snow on the ground, but the weather is 
going to be 60 degrees and it is a little easier for everybody 
to come, but the fact that you adjusted your schedules, I also 
appreciate. We have got a great group of witnesses.
    This is a huge problem, and what I thought I would do, just 
to kind of give you a sense of how we will run this hearing 
until about 12:30, is I will make some opening comments. I will 
introduce the witnesses that we have before us who are going to 
testify. They will each testify for 5 minutes or so, and then I 
am going to be a lawyer and cross examine them. I have a lot of 
questions for these witnesses, and all of this testimony will 
be available on the record in the--if you just go to the Aging 
Committee of the Senate, this testimony will be available.
    We have had hearings on this issue and meetings on this 
issue in D.C. and we are looking to have field hearings so that 
we can make appropriate policy.
    Just a word about the Aging Committee, wonderful Chair 
Susan Collins of Maine and the Ranking Democratic Member is 
Claire McCaskill of Missouri. It is a committee that works very 
hard, and unlike some Senate committees where the main focus of 
those committees is pushing through legislation or nominations, 
the Aging Committee's primary purpose is to shine a spotlight 
on problems. It is really more of a, you know, let us raise 
issues to the public consciousness.
    One example that we have, for example, on the Aging 
Committee, we have a 24/7 hotline for seniors to call and 
report abuse, financial scams or consumer scams that trap 
seniors, so our main interest in this Committee is to kind of 
raise the profile of tough issues, and then once raised, often, 
individual members or sometimes even other committees, like the 
HELP Committee--HELP, Health, Education, Labor, Pension--will 
take the issues whose profiles have been raised when we do 
these field hearings and then we will put through legislation 
about them, but let me just start and now make some opening 
comments and then we will move to the witnesses and their 
testimony.
    Let me thank Loudoun County Government. Let me thank the 
Loudoun County Area Agency on Aging. These local Areas on 
Aging, Loudoun County does such a good job around Virginia, and 
the Loudoun County Government has been gracious to host this 
today, along with officials from Leesburg, who have been 
introduced. These Areas on Aging throughout Virginia, and I 
learned when I was Mayor and Governor they do great work for 
our seniors and they work to improve quality of life in so many 
different directions. I want to thank my committee staff and 
committee chair and my personal staff for helping with this 
issue, and it is an issue of passion for me because it is an 
issue that affects every last zip code and region of Virginia. 
It respects not race, not region, not income, not age, and I 
have had town hall meetings about the issue of opioid addiction 
in far Southwest Virginia, in Winchester, meetings in Richmond 
with Governor McAuliffe, and now here in Leesburg.
    All across the Nation, we are seeing a scourge of 
prescription drug and heroin epidemic, and they interrelate 
very significantly, and they impact communities everywhere. 
From the coal mines of Appalachia to suburban Fairfax County, I 
have heard from parents who have buried children, law 
enforcement officials, and employers who struggle to find 
employees who can find a drug test. I have heard from law 
enforcement officials who have talked about the struggles that 
their own children have had with opioid addiction.
    Deaths from drug overdoses have jumped in nearly every 
county across the United States, and it has been driven largely 
by an explosion in prescription pain killers that often then 
connect with heroin addiction.
    The number of deaths from opioid addiction reached a new 
peak in 2014, 47,055 people, 125 Americans every day, and 
nationally, opioids were involved in more than 61 percent of 
overdose deaths in 2014, so there are other drug categories, 
obviously, that can lead to overdose deaths, but opioids is now 
the driving force, and the deaths from heroin overdoses has 
tripled just since 2010. From 2010 to 2014, overdose deaths 
have tripled.
    This is a problem that really begins largely in our 
medicine cabinets. Opioids, including hydrocodone, which is 
commonly known as Vicodin, oxycodone, which is commonly known 
as Oxycontin, and oxymorphone, or Opana, are among the most 
commonly prescribed medicines in the United States. Over the 
past 15 years, the rate of opioid pain reliever use in the 
United States has soared. Over 259 million prescriptions for 
opioid pain killers were written in the United States in 2013, 
and, obviously, a prescription contains multiple pills, so the 
number of actual pills prescribed has been dramatic.
    This is a kind of pain killer that has a very important 
use. It was developed primarily for palliative end-of-life care 
when someone is dealing with terminal pain at the end of their 
life, or with very acute pain management, for example, 
following surgery. That was how these important medicines were 
developed, and they do have an important purpose in that area, 
but what has happened is that they have been prescribed far 
beyond their original intent to include chronic pain 
management, which was not the original purpose of these 
medications, and as that has happened, the prescription of 
opioids--prescription opioids has gone dramatically up.
    According to the Centers for Disease Control, the rise in 
opioid pain reliever consumption has led to, and this is the 
CDC talking, quote, ``the worst drug epidemic in history,'' and 
that is a mouthful. The CDC has recently added opioid overdose 
prevention to its list of the top five public health challenges 
in the United States.
    The opioid epidemic closely is related to the increase in 
heroin use, so a common etiology of addiction that we see is 
people who get prescribed for legitimate reasons a prescription 
opioid. They then become addicted to it. The cost of it becomes 
to hard to bear, and because of some changes in heroin, 
especially its production now in Central America and Mexico, 
not just in Turkey and Afghanistan, the price of heroin drops, 
and so people who get addicted and then cannot afford the 
prescription opioid decide to try to see if they can buy 
heroin, which is cheaper, and so, then they become addicted to 
heroin, and often heroin that is cut with all kinds of other 
drugs. They do not know the purity of it. They do not know what 
other problems are in it.
    Four-fifths of those who die from heroin overdoses started 
their addiction to opioids with prescription drugs, so these 
prescription drugs not only cause a problem in and of 
themselves when used improperly, but they also become kind of a 
gateway into heroin and the heroin overdose problem that is 
directly connected to it.
    This is a crisis that a lot of people in their mind's eye 
think about young people, and certainly, the effect of opioid 
addiction and overdoses on young people have been staggering. I 
was fortunate enough--``fortunate'' is kind of a hard word, but 
I was fortunate enough to have as my guest at the State of the 
Union this year a wonderful Fairfax dad whose son--this is Don 
Flattery--whose son was a UVA grad who moved to L.A, and then 
got hooked on prescription drugs and died, and he has turned 
his tragic experience into a real passion in advocating for 
others, and we often think about this problem in connection 
with young people, and that is appropriate. However, this does 
not respect age and this problem is beginning to have a very 
particular and dramatic impact on older Americans.
    Deaths from drug overdoses have steadily increased among 
older adults. According to the CDC--this is now 2013 data--more 
than 12,000 Baby Boomers died of accidental drug overdoses, 
more than the number who died in car accidents or from the flu 
or pneumonia combined.
    The age group with the fastest rise in overdose deaths due 
to prescription abuse is the age group of 55 to 64 years old, 
and this is an indicative pattern of the larger problem of 
opioid abuse. It normally does not start with illicit drug use. 
It starts with getting a prescription that is written for a, 
you know, a standard medical problem involving pain management, 
but this expansion of how opioids are prescribed beyond 
palliative and acute pain management to chronic pain management 
has been one of the major problems.
    Among older adults, there are some other challenges that 
compound this. Older adults take more medications, on average, 
than younger people, and there are some particular problems of 
the combination of opioids with other drugs and the medical 
effects that they can have.
    Older adults may, for other reasons, eyesight and others, 
start to have a little more challenge with operating motor 
vehicles, and again, any use of prescription drugs or something 
like that, when combined with some of the challenges that some 
of our seniors have with operating heavy vehicles, motor 
vehicles, can lead to these problems.
    Now, we talked about the problem from a national problem, 
but just quickly some of the Virginia stats. As I said, I have 
done roundtables on this issue in all corners of the State. The 
Virginia Department of Health--and we are going to hear from 
patient advocates, people who have had these experiences touch 
them deeply in their own family, Virginia and local officials--
you know, this is the work Phyllis has done in her other 24-
hour-a-day job next to being Chairman of the Board, and also my 
good friend Attorney General Herring, who has worked so 
significantly on this--we see it all over Virginia, and the 
Virginia Department of Health reported that the increase in 
deaths in prescription opioid and heroin overdoses just between 
2012 and 2014, a 2-year period, the increase in opioid-related 
deaths went up by nearly 40 percent in 2 years. The Attorney 
General is going to focus on some additional statistics that 
are Virginia-specific as he testifies, so what is the solution 
to this challenge? Well, it is going to take a big cultural 
shift to get away from a culture of over-prescription and a 
culture that uses other methods for managing chronic pain. 
Again, these opioids, the prescription opioids, have a 
legitimate and important use. They definitely do, but the 
challenge we have is one of an over-prescription that has 
really kind of run wild, and there is no single thing that will 
affect that. Raising awareness is part of it, but there are 
also steps that we must take.
    Just quickly, some of the things that I have been involved 
with in the Senate is, first, as a member of the Armed Services 
Committee, I have been very involved in efforts to go into our 
DOD medical facilities, hospitals, clinics, and our VA medical 
facilities and clinics and to make sure that they are using 
appropriate standards in terms of how they deal with pain, that 
there is a place for prescription opioids, but they should not 
be over-prescribed, and other pain management strategies, 
especially for chronic pain, are really important to make sure 
that we pursue, so in those areas, I have been working a lot on 
my committee.
    I have introduced a bill called the Co-Prescribing Saves 
Lives Act, which deals with the co-prescription of naloxone. 
Now, many in this room are much more expert about this than me, 
but naloxone is a drug that has been used, really, since the 
early 1990's or so that can bring someone back from an opioid 
overdose, commonly an opioid overdose that is driven by 
respiratory failure, and naloxone is an easily administered 
drug that will--it is not pleasant. It is like going through 
withdrawal immediately, but it brings you back out of the 
respiratory failure that an opioid overdose creates.
    It has been very common for naloxone to be carried by first 
responders and used by first responders if people are in an OD 
situation. One of the virtues of naloxone is if you think 
somebody has overdosed and you administer it and it turns out 
there is something else wrong, that naloxone does not have a 
negative side effect if it is actually something else other 
than an OD, but if it is an OD, it will bring folks back, but 
the use of naloxone has kind of been limited to first 
responders, but there is a growing awareness that naloxone 
should be co-prescribed and should be in the medicine cabinet 
of people who get prescribed opioids, especially if they have 
other risk factors. Like, if they have a history of respiratory 
illness, that would be a circumstance where the co-prescription 
of naloxone as an automatic would make a lot of sense, so I 
have introduced one bill called the Co-Prescribing Saves Lives 
Act, which will push the feds to establish a meaningful set of 
protocols around when naloxone should be co-prescribed.
    We have a bill called the Stopping Medication Abuse and 
Protecting Seniors Act, which would prevent inappropriate 
access to opioids for at-risk beneficiaries. There is already a 
program in Medicaid that sort of--it is called a pharmacy lock-
in where you can choose your own pharmacy, but you cannot go to 
multiple pharmacies to get an opioid prescription if there are 
certain risk factors that are connected with your individual 
case. That is part of Medicaid already, and we are trying to 
take that same concept and put it in Medicare so that people 
going to multiple pharmacies and taking multiple medications 
does not contribute to opioid abuse, so these are some 
examples, working in the DOD and VA, the co-prescription issue, 
the idea of a pharmacy lock-in for seniors to impose some 
controls over how opioids are prescribed to seniors, that we 
are working on, but you know, what I have learned in 3 years in 
the Senate is you put legislation on the table that you believe 
passionately in, but it is really important to go out and 
reality check it against the people who are doing the job full-
time to make sure that the solutions that we are proposing are 
as close a match as can be for the actual problem and how the 
problem will be solved, and that is one of the reasons that I 
wanted to come today and to hear from you.
    I really appreciate everybody coming. This is an incredibly 
important topic, and let me just--I have a number of staffers 
here, but I just want to introduce two for followup purposes, 
in case something you hear today makes you want to say, wow, I 
really want to followup, and that is Kristen Molloy, who is 
right here in the brown jacket. Kristen is my advisor on health 
matters, and so works with me on this particular issue in the 
D.C. office, and then Joe Montano, who is standing at the back 
with the purple vest on under his suit jacket. Joe runs my 
Northern Virginia office, which is in Manassas and covers 
Loudoun, so if you have a followup today and you want to reach 
out, either reach out to my Northern Virginia office or my 
policy team.
    Let me now talk about the witnesses that we have. I am 
very, very glad to have everybody here.
    Mark Herring is the Attorney General for the Commonwealth 
of Virginia, and you know Mark very well because he is Leesburg 
and Loudoun born and bred. He is a wonderful AG and a wonderful 
friend.
    Some of you know this. When Mark was a law student at the 
University of Richmond, I was his ethics professor, so that 
makes me particularly proud of him. I used to teach part-time 
at UR when I practiced law. In the spring of 1987 to 1993, I 
taught legal ethics and ended up having Mark as a student, and 
it has been wonderful to reconnect with him and work with him 
in so many ways.
    Mark works to keep Virginia families safe in their 
communities and neighborhoods and provides legal services to 
every agency of State government, the colleges and 
universities. He does a lot, but on this particular issue--and 
you are going to hear about some of his office's initiatives--
he has launched a five-point plan to combat heroin and 
prescription opiate abuse by creating and implementing 
partnerships and creative solutions with stakeholders in all 
regions of the State to solve this complex problem, and we are 
very, very glad to have him.
    Let me go to Jane Terry. Jane is the Director of Government 
Affairs for the National Safety Council. The NSC is a 
congressionally chartered nonprofit safety organization whose 
mission is to prevent injury and save lives in homes, 
communities, and in the workplace. She is an experienced policy 
and legislative leader. She has nearly 20 years of experience 
working with local, State, and Federal Government officials on 
transportation, telecom, workplace safety, community 
development, and health care initiatives, and she is going to 
speak about the NSC's work on opioid safety issues. Thank you, 
Jane, for being here.
    Dr. Katherine Neuhausen is the Assistant Professor of the 
Department of Family Medicine and Population Health at VCU, 
which is my neighborhood university. I live in Richmond just a 
mile or so from the VCU campus. She is also the Associate 
Director of the Office of Health Innovation. Katherine has led 
the development of innovative statewide models to integrate 
mental health and substance abuse treatment and primary care 
and also to address the needs of---high needs--high costs, high 
needs, and complex patient populations. Dr. Neuhausen conducts 
research on the health care costs associated with untreated 
mental illness and substance abuse, and she recently co-
authored a policy brief on the opioid crisis among Virginia 
Medicaid beneficiaries. Dr. Neuhausen, thank you so much for 
being here.
    Lisa Wilkins is the Acting State Director for Virginia 
Change Addiction Now, and Lisa has a very, very powerful story. 
She is a resident of Berryville. She comes to us today with a 
full range of experience with this most challenging issue and 
understands its complexities well. Despite a very stable 
working family with loving and involved parents, both of Ms. 
Wilkins' sons fell prey to the epidemic plaguing our State and 
our country. She lost her oldest son in 2011 at age 23 to a 
heroin overdose. Her youngest son, who is now 26, is currently 
in recovery from his own battles with prescription pain 
medication and heroin. She is a primary caregiver of her 
disabled mother for 15 years, until her mother passed in 2013, 
and she is familiar with many of the issues that face not only 
the young population I was describing earlier, but also with 
the families and with seniors. It is so hard for somebody who 
has been through such a tragic experience to just come and be 
willing to share it, but sharing it is what she is doing so 
that she can try to lift the burden and, hopefully, create a 
path for others, and Lisa, we are really, really happy you are 
here.
    We do have one other witness who might come, and let me go 
ahead and just do the--she is 10 minutes out? Okay. Well, we 
will make her speak last and she will come here, but let me 
just tell you about her. She will eventually come in and sit 
next to Attorney General Herring, and it is Mellie Randall. She 
is the Director of the Office of Substance Abuse Services for 
the Virginia Department of Behavioral Health and Developmental 
Services.
    For 27 years while Mellie has been at the Department, she 
has focused on planning and policy related to treatment 
services for people with substance abuse disorders. She played 
a key role in a statewide project focusing on improving access 
to integrated treatment for individuals with co-occurring 
mental illnesses, and she has just worked on this in so many 
different ways, but most recently and especially, and Attorney 
General Herring knows this, she has been serving as staff to 
Governor McAuliffe's Task Force on Heroin and Prescription Drug 
Abuse. Former Congressman Wolf and I and a bunch of the 
Virginia legislators wrote a letter to Governor McAuliffe at 
the start of his term and asked that he set up a statewide task 
force on this and Mellie has been the key staffer helping that 
task force succeed.
    The last thing I will say, and then I am going to have the 
witnesses testify, is, you know, when you are in public life, 
you work very hard to do good things, but then it is important 
also to look back at what you have done and say, hmm, was that 
the right thing, or did we miss an opportunity, or what did we 
learn from it, and you know, I had an interesting experience 
when I was Governor. We had a very, very serious problem with 
methamphetamine during those times really kind of taking root. 
Now, we still have a methamphetamine problem in Virginia, but 
this was really acute, and this was the one that was getting 
attention, and we worked together. Mark was in the State 
Senate, and we worked together with others to do some things to 
tackle the meth problem to basically take some of the precursor 
drugs for meth that could be bought out in the drug store and 
move them behind the counter so that they would be harder to 
do, and it did have an effect and we felt pretty good about it.
    I was starting into my tenure in the Senate and traveling 
around the State and hearing about the opioid abuse problem, it 
suddenly struck me that what we did was we treated a symptom 
when we did that, but we really did not treat the cause. You 
know, we made it harder for people to get some of the drugs to 
create methamphetamine, so that was good, but that was creating 
a symptom. We were not really going into the cause, and so, if 
we made it harder to get meth, but we did not deal with the 
cause, people would figure out another way to use some other 
kind of drugs, and so, I think what we are really grappling 
with is treating symptoms is fine. You have got to treat 
symptoms, but the more we understand so that we can move to a 
model where we are really addressing causes, then, we are going 
to be even more successful, and I feel very dedicated to doing 
that and I look forward to learning from these witnesses today 
and bringing that learning to the attention of my committee 
members, and with that, I applaud my friend Mark Herring for 
coming, and Mark, I will turn it to you.

                  STATEMENT OF MARK HERRING, 
           ATTORNEY GENERAL, COMMONWEALTH OF VIRGINIA

    Mr. Herring. Senator Kaine and members of the United States 
Senate Special Committee on Aging, thank you for shining a 
light on issues of addiction among older Virginians, an 
affected population that too often goes unnoticed.
    To help set the stage for today's discussion, I would like 
to share some information about the scale of the problem in 
Virginia, efforts underway at the State level, including from 
my office to combat the problem, and some senior-specific 
strategies that we are employing and opportunities to do even 
more to protect this potentially vulnerable population.
    During my time as Attorney General, I have seen firsthand 
the impacts of a heroin and prescription drug crisis that is 
claiming the lives of hundreds of Virginians every single year 
and touching families in every corner of the Commonwealth. In 
2014, heroin and prescription drug overdoses claimed the lives 
of 728 Virginians. That is more than car crashes, and that 
number is shocking and it is heartbreaking. Over the last 5 
years, more than 3,000 Virginians have lost their lives. This 
is a problem that is cutting across all social and demographic 
lines.
    After speaking with so many mothers and fathers who have 
buried a child after a fatal overdose, or friends and family 
who are trying to carry on after the loss of a loved on, I have 
also learned that what is often described as a heroin epidemic 
is really an opioid addiction epidemic. Something as common as 
a sports injury, a car accident, or a minor surgery can expose 
a person to opioids, leading to abuse, dependency, and in the 
worst cases, leading to the cheaper, more available, more 
potent and deadlier heroin that can be found on the streets.
    The Centers for Disease Control estimate that one in 15 
persons who take prescription pain killers for non-medical 
purposes will try heroin within 10 years, and that is a fast 
and frightening slide, so to properly address what is often 
called the heroin epidemic, we must acknowledge that this is a 
heroin and prescription drug abuse epidemic that has its roots 
not in the streets, but in our medicine cabinets, and given the 
amount of opioids prescribed to older Virginians, we should 
begin accounting for their needs and risk factors as we work to 
address addiction.
    According to preliminary numbers from the Virginia Office 
of the Chief Medical Examiner, through September 2015, 120 
Virginians age 45 to 54 died of a heroin or prescription drug 
overdose. That is the third highest age cohort, and fourth 
highest is age 55 to 64. More Virginians age 55 to 64 died of 
heroin and prescription drug abuse--drug overdose--than age 15 
to 24.
    It is almost unimaginable to think about someone becoming 
dependent on a drug for the first time at that age, but that is 
the power of these drugs and it is a reality that more and more 
of our friends, neighbors, and parents are confronting. These 
are the Virginians who are about to age into certain medical 
assistance programs and whose struggle with addiction is likely 
to place an even greater strain on limited public budgets.
    For example, in 2014, Virginia's Medicaid program spent 
approximately $27 million on prescription pain killers. That is 
up about 30 percent from 2011. I think it would be safe to 
assume that the Federal Government is noticing similar 
increases and will continue to, especially as our population 
ages.
    In Virginia, I feel somewhat fortunate because it seems 
like we have recognized and are responding to this problem 
somewhat faster than other states. In my office, we are coming 
at the problem with a multifaceted strategy that includes 
prosecutions and enforcement as well as legislative solutions, 
prevention, and education.
    In the last year and a half, we have worked with our local 
and Federal partners to prosecute more than 28 cases against 
dealers and traffickers involving more than 95 kilograms of 
heroin with an estimated street value of more than $19 million. 
That is about 238,500 daily doses.
    We have also launched a number of prevention and education 
initiatives to make sure everyone--young people, parents, 
adults, even seniors--understand just how dangerous these drugs 
can be. One of the centerpieces of our prevention efforts is a 
documentary film called, ``Heroin, the Hardest Hit,'' which 
really puts a face on addiction in Virginia. It features 
Virginians sharing their own stories of addiction, even 
overdose, and, thankfully, recovery. It also tells the story of 
some wonderful young people who, unfortunately, lost their 
lives to these drugs, and the parents and families left to 
carry on without them.
    We also worked with the General Assembly in 2015 to enact 
three life-saving overdose prevention laws with bipartisan 
support. One created a Good Samaritan provision to encourage 
people witnessing an overdose to call 911 and get help.
    Another expanded the availability of naloxone, a life-
saving overdose antidote, so that all law enforcement and first 
responders can carry it and more families can get it without a 
prescription, and, finally, we expanded access to the 
Prescription Monitoring Program to make sure that probation 
officers can monitor their probationers to make sure they are 
not getting drugs that they are not allowed to have.
    Those last two bills, I think, offer some lessons that 
could be particularly applicable to senior populations and to 
our efforts to address addiction among older Virginians. I look 
forward to discussing them throughout today's hearing.
    To conclude my remarks this morning, I will just again say 
thank you to this Committee and thank you to Senator Kaine for 
keeping the issue of addiction in the forefront and for giving 
particular attention to seniors and older Virginians who may be 
struggling with addiction, and I join you in sounding the alarm 
about the heroin and prescription drug crisis and I want every 
family in Virginia to be talking about it now, not once there 
is already a problem, or, God forbid, after a loved one is 
lost. We have to start now, because I have heard from so many 
heartbroken parents who have lost a child and so many 
devastated families who have lost a loved one, and they all 
say, ``I never thought this could happen to my family.''
    Thank you for allowing me to join you today, and I look 
forward to discussing those issues and answering any questions 
the Committee may have.
    Senator Kaine. Thank you, General Herring.
    Jane Terry.

               STATEMENT OF JANE TERRY, DIRECTOR 
         OF GOVERNMENT AFFAIRS, NATIONAL SAFETY COUNCIL

    Ms. Terry. Thank you, Senator Kaine, for inviting the 
National Safety Council to participate in this hearing today. 
NSC is a 100-year-old organization dedicated to fighting the 
causes of unintentional death and injury. As such, we took note 
of the alarming trend of increasing drug poisonings due to 
prescription opioid pain killers over the last decade.
    As you mentioned, Senator Kaine, this is an epidemic that 
knows no income or age restrictions and one that touches the 
lives of so many Americans. I appreciate your highlighting the 
specific impact this epidemic has had on our aging population.
    The data clearly show the scope of this epidemic. Opioid 
overdose deaths, once rare in the United States, have resulted 
in more than 220,000 lives lost in the past 15 years, 175,000 
from pain killers and 45,000 from heroin. Each day, over 50 
people die from an opioid overdose.
    As stated previously, addiction can occur at any age. Here 
are a few of the facts about older adults and opioids. Nine 
million Medicare Part D beneficiaries fill prescriptions for 
opioids to treat conditions not associated with cancer or 
hospice. More than 1.7 million of these patients received a 
dose that put them at increased risk of overdose, and nearly 
225,000 received these high doses for more than 90 days.
    Also, older adults who take opioids are five times more 
likely to suffer a fracture, and falls are the leading cause of 
unintentional death for adults 65 years of age and older. They 
are also over twice as likely to have a heart attack. They are 
50 percent more likely to have kidney damage and 50 percent 
more likely to die while taking the medication.
    Together, we can do more to stop these trends. NSC strongly 
supports your legislation, the Co-Prescribing Saves Lives Act. 
This is important legislation that would enact meaningful 
changes in the Federal health care system to save lives, where 
in 2012 nearly 14 million people received health care through 
the VA or military health systems.
    This legislation also takes the important step of co-
prescribing naloxone, as we have mentioned here today. Naloxone 
saves lives and it should be easily accessible and readily 
available to those who are taking opioids. Also, loved ones of 
people addicted to heroin and first responders should also be 
able to access naloxone.
    Today, I brought a naloxone demonstration device to show 
how easy it can be to administer. There is no needle or 
medication with this.
    [A demonstration was shown.]
    Ms. Terry. As you can see, some of these devices are 
extremely easy to administer, so NSC appreciates your support 
for----
    Senator Kaine. I cannot resist in saying that method for 
delivering naloxone, and it used to be common as a nasal spray 
or delivered otherwise, was developed by a Virginia company 
called Kaleo that used that same technology to deliver other 
kinds of drugs, but it basically tells you how to do it. You do 
not have to memorize the instructions. You tear a strip and 
then it talks you through what to do so that in the event of an 
emergency or somebody who has not been trained can follow it. 
It is a really simple way of administration.
    Back to you, Jane.
    Ms. Terry. The opioid epidemic has been largely fueled by 
prescribers who are not aware of the fatal risks associated 
with their use. NSC believes that doctors who apply to the DEA 
to prescribe controlled substances should be required to take 
classes about effective pain treatment and signs of addiction. 
Some states have already implemented this requirement and it 
should be a national requirement.
    DEA has done great work removing the excess supply of 
opioids and other medications from homes through drug take-back 
days. The one held just this last October collected 350 tons of 
unused drugs. The next take-back day will be on April 30, and 
we urge continued congressional support of these events.
    Finally, NSC supports the CDC prescribing guidelines as 
proposed and we believe these should be quickly implemented. We 
appreciate your support of these guidelines, as well. These 
guidelines incorporate the best evidence available at this 
time. They encourage better information sharing between doctor 
and patient. They discuss the dangers of long-acting and 
extended release opioid pain relievers. They support co-
prescribing of naloxone, encourage the use of PDMPs, and 
educate providers about dangerous opioid interactions with 
other medications. The guidelines will save lives without 
evidence that pain treatment will be diminished.
    Thank you, Senator Kaine, for inviting the National Safety 
Council to participate today, and I look forward to responding 
to your questions.
    Senator Kaine. Thank you very much, Jane.
    Dr. Neuhausen.

        STATEMENT OF KATHERINE NEUHAUSEN, M.D., M.P.H.,

           ASSISTANT PROFESSOR, DEPARTMENT OF FAMILY

         MEDICINE AND POPULATION HEALTH, AND ASSOCIATE

             DIRECTOR, OFFICE OF HEALTH INNOVATION,

                VIRGINIA COMMONWEALTH UNIVERSITY

    Dr. Neuhausen. Senator Kaine, thank you for this 
opportunity to examine the growing epidemic of prescription 
opioid misuse and abuse among older Americans.
    I am a family doctor in practice in Virginia Commonwealth 
University's Hayes E. Willis Health Center, which is located in 
an underserved community in the south side of Richmond. I am 
here today because of the many patients I care for of all ages, 
races, and socio-economic classes who have experienced the 
devastating effects of the opioid epidemic.
    I would like to share a patient story that illustrates the 
potential long-term harm from taking opioids, even when 
prescribed by a physician. One of my former colleagues started 
an older female patient on opioid pain relievers for her 
chronic pain several years ago. This physician continued to 
increase the dose over time without adequately screening for 
side effects. One evening, her patient fell down the stairs 
after taking her evening dose of the opioid, likely because of 
dizziness and confusion caused by the medication. The fall 
resulted in a severe foot injury that required surgery. The 
patient's foot never fully healed and she ended up in a 
wheelchair, and she is requiring even higher doses of opioids 
now for the chronic foot pain resulting from her fall.
    Today, I will discuss how this patient's story is not 
unique, but is part of the epidemic of prescription opioid 
misuse and abuse among older Americans and the general 
population. I will also explain the potential risks and harms 
of prescription opioids, including the fact that people, 
especially the elderly, can overdose even when they take 
opioids as prescribed.
    I will talk about three possible solutions to this 
epidemic. First, we need better provider education. Second, we 
need to increase the use of evidence-based guidelines among 
providers prescribing opioids, and third, we need to increase 
access to evidence-based addiction treatment.
    Prescription opioid pain relievers are the molecular 
cousins of heroin and are just as addictive as heroin. 
Prescription opioid abuse and misuse has become a public health 
crisis in our country. In 2014, overdoses from opioid pain 
relievers far exceeded deaths from any other legal or illegal 
drugs.
    Opioid pain relievers can be harmful whether they are taken 
without a prescription or start with a prescription from a 
doctor. Many individuals who end up addicted to opioids start 
out with a legal prescription given to them by a health care 
provider. The provider may have given them too high a dose, or 
too many pills, or too many refills, causing them to become 
addicted and to take even higher doses to obtain the same pain 
relief until often they eventually overdose.
    In fact, opioid overdoses appear to occur more frequently 
in people using opioids for medical reasons, such as chronic 
pain, than in recreational users. One study found that over 90 
percent of the individuals who overdosed in a State had 
received a legitimate prescription for an opioid pain reliever 
from a health care provider.
    A number of recent studies have concluded, as Senator Kaine 
mentioned, that opioids are not very effective in treating 
chronic non-cancer pain or improving function and can cause a 
number of harmful side effects, and this is not surprising 
considering that all the studies of their effectiveness were 
conducted for patients with chronic cancer-related pain, 
palliative care needs, and acute pain, so there are also high 
rates of death from intentional overdoses, especially at high 
doses of opioids that tend to be given to treat chronic non-
cancer pain.
    Older Americans have the highest risk of these harmful side 
effects. Many other medications are more effective than opioids 
in the treatment of chronic non-cancer pain and have far fewer 
risks, but these other medications are not always tried first.
    We can take several steps to address this public health 
crisis. First, greater Federal and State funding is required to 
train health professional students and medical residents in 
pain management and opioid prescribing, as well as in screening 
and treatment of substance use disorders.
    States should be encouraged to create mandatory annual 
continuing medical education requirements in appropriate opioid 
prescribing for providers. Virginia does not currently have 
this requirement, but proposed legislation under consideration 
by the General Assembly would require all physicians to obtain 
this education.
    Second, health care providers need prescribing guidelines 
that decrease the risks of addiction and overdose for their 
patients. I applaud Senator Kaine for his recent letter urging 
the Centers for Disease Control to release long-awaited opioid 
prescribing guidelines. As a practicing primary care physician, 
I strongly support these guidelines and believe that they 
should be released as soon as possible. I am not alone. A 
survey showed that 87 percent of physicians support the CDC's 
guidelines and would use these guidelines in practice.
    The Co-Prescribing Saving Lives Act sponsored by Senator 
Kaine is also an important step in the right direction. By 
creating physician education and guidelines that encourage 
doctors to co-prescribe naloxone when they prescribe opioids, 
this legislation would prevent opioid overdose deaths.
    Third, we must increase access to evidence-based addiction 
treatment. Only one in ten people with addiction involving 
alcohol or drugs other than nicotine receive any form of 
treatment, and of those who receive treatment, few receive 
evidence-based care, and I believe that this is part of the 
root cause that Senator Kaine mentioned. When supply is shut 
down to drugs of choice and people remain addicted and do not 
receive the counseling, psycho-social therapy that they need to 
get better and to address the past childhood trauma or adult 
trauma that often leads to the addiction, they will just switch 
drugs and continue to find a drug to treat the emotional 
physical pain, so medication assisted treatment, or MAT, with 
suboxone or methadone and counseling is an evidence-based 
treatment for opioid addiction that can help people with 
addiction recover and become functioning members of society, 
and I compare MAT for opioid addiction to insulin for diabetes. 
The vast majority of people with opioid addiction will not get 
better without the medication assisted treatment.
    Over 4.5 million people need but are not receiving 
substance abuse treatment in the U.S., many with opioid 
addiction. The shortage of physicians trained in MAT has 
created long waiting lists, requiring people to wait many 
months to receive life-saving treatment. Federal and State 
health agencies should offer more grant opportunities to train 
physicians and support primary care practices in offering MAT.
    Congress could also make a difference by passing the 
Comprehensive Addiction and Recovery Act, which would designate 
up to $80 million to advancing substance abuse prevention and 
treatment in State and local communities. Since every one 
dollar invested in substance abuse treatment returns seven 
dollars in cost savings to the health care and criminal justice 
system, this would be a wise use of taxpayer dollars.
    Finally, Virginia's Medicaid program, like Medicaid in many 
states, pays very poorly for addiction treatment. As a result, 
providers do not provide treatment. Many would like to, but it 
is not worth their time. To increase access to treatment, 
Virginia's General Assembly is currently considering a proposed 
substance use disorder treatment benefit that would reform 
Medicaid so that Virginians currently eligible for Medicaid 
would have access to the evidence-based treatment proven to 
cure addiction. This includes in-patient detox, residential 
treatment, outpatient treatment including medication assisted 
treatment, care coordination, case management, and peer 
recovery coaches. Since Medicaid members are twice as likely to 
be prescribed opioids as their peers with commercial insurance 
and have a six times greater risk of overdose deaths, this 
benefit would help a vulnerable population and save lives.
    As a family doctor, I see the devastating consequences of 
opioid abuse daily. The steps that I have outlined today--
increasing provider education, implementing evidence-based 
guidelines, and increasing access to evidence-based addiction 
treatment--should be part of a comprehensive strategy. We have 
a tremendous amount of work to do to end this epidemic.
    I would like to thank Senator Kaine for the opportunity to 
testify and for his leadership in addressing a public health 
crisis that is impacting all Americans.
    Senator Kaine. Thank you, Dr. Neuhausen.
    Ms. Wilkins--and Director Randall, it is great to have you, 
and after Ms. Wilkins testifies--your timing is perfect, so 
thank you.
    Ms. Wilkins.

               STATEMENT OF LISA WILKINS, ACTING 
         STATE DIRECTOR, VIRGINIA CHANGE ADDICTION NOW

    Ms. Wilkins. Thank you, Senator Kaine, distinguished 
witnesses, and guests for including me in this important field 
hearing to discuss potential solutions to what the Centers for 
Disease Control has declared the worst opioid epidemic our 
country has ever faced. This public health crisis has arrived 
in every corner of the country, in Virginia, and with a 
vengeance in Northern Virginia and my home in the Shenandoah 
Valley.
    My name is Lisa Wilkins. I am a 20-year resident of 
Berryville, Virginia, and speaking today as a concerned citizen 
and a dues-paying member of the sandwich generation. I have 
been impacted as both a parent and as a daughter.
    I have recently been named Acting Director of Virginia CAN, 
Change Addiction Now, an advocacy organization dedicated to 
bringing the family voice to addiction and recovery in Virginia 
communities, assisting families seeking information about 
treatment and recovery, reducing the stigma associated with 
addiction, and promoting harm reduction and public policy 
designed to stem this tide of substance use disorder. I am also 
a chapter leader for the local Grief Recovery After a Substance 
Passing peer support group, which reaches out to support 
families who have lost a loved one to this devastating disease.
    I come to you today with several perspectives, all of which 
have had varying degrees of personal impact, and I will put a 
picture and faces to our story. I believe these perspectives 
illustrate the range of those in our society whose pathways to 
addiction can be the result of non-medical use or abuse as well 
as those who become addicted through medically prescribed pain 
medications through overuse or misunderstanding. Both pathways 
are implicative in today's explosive crisis.
    In the case of my sons, the youngest, that you see in the 
picture below with a hat on, was exposed to prescription 
opioids, like many youth today, through their widespread 
availability among peers and schoolmates. Both sons were 
treated with prescription opioids after childhood injuries, the 
oldest after being mauled by a dog at age 11, and the youngest 
after a motor vehicle accident at age 15.
    In addition to the youth affected by prescription opioid 
misuse, an often overlooked population at risk are older 
patients. One such case involved my mother. She was exposed to 
prescription opioids as a course of treatment for her chronic 
pain. Throughout her care, her doctor and I had to consider a 
myriad of safety issues in treating her with opioids, from 
falls, to unintentional use through confusion, to kitchen fire 
potential, to actually becoming a victim of crime. Those risks 
were evaluated against her comfort, quality of life, as well as 
the anticipated dosages and length of treatment. Very often, 
alternative treatments were explored, and when higher dose 
opioid therapy was necessary, she was treated under 24-hour 
supervision by myself or admitted to a skilled nursing 
facility.
    The lesson I learned from my mother's pain treatment is 
that this type of doctor, patient, and family medical 
decisionmaking should be the standard of care, not the 
exception. My mother and our family were very lucky. Others who 
may not have had engaged family members or attentive physicians 
may have had far more tragic experiences.
    With over 259... [sic] opioid prescriptions written in the 
U.S. as recently as 2012, these drugs are filling our 
communities, our workplaces, our schools, and our medicine 
cabinets, making them widely available for misuse. It is easy 
for our youth and elderly alike to misjudge the addictive 
nature of prescription opioids, not realizing that they are a 
family to their synthetic cousin heroin, and often believe that 
using prescription opioids are safe. One of the lessons here is 
that more widespread education and awareness aimed at both the 
youth and the elderly is a critical part of any solution to 
address this crisis.
    As you mentioned, the age group with the fastest rate of 
overdose deaths due to prescription opioids is 55 to 64 years 
old. In addition, according to the National Association of 
Medicaid Doctors, Medicaid patients are two times more likely 
to be prescribed opioids and six times more likely to suffer 
overdose death. These populations are overlooked as medical 
practitioners, clinicians, and policymakers pursue strategies 
to address the opioid addiction and mortality crisis. This must 
change.
    I am pleased to learn through your leadership you have 
developed two specific legislative proposals which will have a 
dramatic impact in preventing further prescription opioid 
misuse, abuse, and potentially save the lives of those at risk 
from overdose events. The Co-Prescribing Saves Lives Act is a 
common sense measure to provide access to the overdose-
reversing and life-saving drug naloxone. The availability of 
this drug to family members, especially to those involved in 
elder care, is a powerful mechanism to save lives. There is no 
good reason to fail in prescribing naloxone with opioid 
prescriptions.
    Further, family caregiver education and inclusion goes 
hand-in-hand with offering this life-saving antidote, which can 
but is unlikely to be self-administered. The bill will ensure 
that anyone at risk for experiencing or witnessing an opioid 
overdose will be thoroughly educated in both the signs and 
symptoms of overdose as well as the administration of naloxone.
    As further justification for co-prescribing naloxone and 
the involvement and education of family members and caregivers, 
I would like to point out that primary caregivers rarely 
provide a heart patient with a prescription for nitroglycerine 
without reviewing its use and administration with family 
members. Likewise, diabetes care education includes family 
members of the diabetic by the very nature of its risks and 
treatment. Opioid therapy should be no different.
    I am also supportive of the Stopping Medication Abuse and 
Protection Seniors Act, which will authorize the use of patient 
review and restriction programs in Medicare. The proposed lock-
in or primary pharmacy use just makes logical sense to ensure 
the reduced risk of dangerous drug combinations and 
interactions, as well as providing a vehicle to identify 
potential drug-seeking behaviors and facilitate early 
intervention.
    There may be a tradeoff between the perceived privacy issue 
and the very high risks associated with opioid therapies. 
Additionally, while many seniors and their families, like mine, 
may shop multiple pharmacies as a method to contain the high 
cost of prescriptions, the risk of potentially overlooking one 
single adverse interaction can be fatal and should not be taken 
lightly. Caregivers may need to start helping seniors manage 
the total cost of their prescriptions rather than the cost of 
each individual medication.
    I believe that these two bills will support a more 
integrated team approach to caring for our seniors. I am 
convinced that these bills are about protecting our most 
vulnerable citizens while making sure that they receive the 
best medical care that we can provide.
    Finally, I would like to end with an endorsement of the 
development of opioid prescribing guidelines--a familiar theme 
today--to better educate physicians in opioid therapies and 
risks. The two bills being discussed today in parallel with 
these guidelines will set the stage for primary care providers, 
their patients, and the patients' caregivers consider adding 
opioid therapy where benefit outweighs the risk and the patient 
fully understands and can weigh in on that risk-benefit 
analysis. The risk-benefit analysis should be used in the 
development of treatment goals, where the parties work together 
to set realistic expectations for pain management and relief 
based on the nature of the chronic pain, with the primary 
drivers being function, patient safety, and quality of life 
versus what may only be an illusion of living pain-free. This 
was a difficult but necessary conversation with my mother.
    Regular evaluation of the treatment plan effectiveness and 
any changes to the risk-benefit analysis can and should be 
conducted in a manner that does not place undue hardship on the 
patient in receiving treatment, obtaining refills, and filling 
prescriptions. These two bills, combined with the additional 
prescribing guidelines, will ensure that family members and 
caregivers are given similar levels of patient education, 
including the signs and symptoms of overdose as well as opioid-
related harms. Family members must be included in the decision 
process, as their observations may not be consistent with 
patients' perception.
    Thank you for the opportunity to discuss this with you 
today, and I would like to place a face on the numbers you are 
hearing. You are talking about 125 faces a day. This is 1 
weekend's worth of prescription opioid and heroin overdose. Two 
days' worth.
    Senator Kaine. Ms. Wilkins, if I could, during the rest of 
the hearing, let me just--I am going to take your family photo, 
if I could----
    Ms. Wilkins. Certainly.
    Senator Kaine [continuing]. your mother and your boys, who 
you have described, because I want to make sure folks who are 
here can see this, too, and, so, kind of make it personal for 
the rest of the hearing, if I can.
    Director Randall, it is time for your testimony. We really 
appreciate you coming. I introduced you and talked about your 
role with the Governor's task force a few minutes before you 
came in, so the crowd is anxious to hear you and I am, too. 
Thank you for participating in this today.

         STATEMENT OF MELLIE RANDALL, DIRECTOR, OFFICE

        OF SUBSTANCE ABUSE SERVICES, VIRGINIA DEPARTMENT

        OF BEHAVIORAL HEALTH AND DEVELOPMENTAL SERVICES

    Ms. Randall. Thank you so much. I apologize for being late. 
I made a wrong turn coming up here from Richmond today.
    Senator Kaine, distinguished panel members and guests, 
thank you so much for this opportunity to participate in this 
important hearing. My name is Mellie Randall and I am the 
Director of the state's publicly funded substance abuse 
treatment services that are provided through the 40 Community 
Services Boards, or CSBs, which are entities of local 
government. I work for the Virginia Department of Behavioral 
Health and Developmental Services.
    The Community Services Boards provide treatment services to 
about 33,000 individuals each year, and they are funded by a 
combination of State and Federal funding that totals about $90 
million. Local tax dollars and fees also help.
    In my role of guiding the use of these resources to provide 
the best possible treatment services, I was privileged to 
provide staff support to Governor McAuliffe's Task Force on 
Prescription Drug and Heroin Abuse. Jointly chaired by 
Secretary of Health and Human Resources Dr. William A. Hazel, 
Jr., and Secretary of Public Safety and Homeland Security Brian 
Moran, the task force began its work in the fall of 2014 in 
response to the growing number of deaths resulting from 
overdose of pain medication such as hydrocodone, fentanyl, and 
the street drug of heroin.
    Currently, at least two Virginians die each day from an 
opioid overdose. Between 2012 and 2014, this number increased 
by 38 percent, and current information from the Department of 
Health indicates that deaths continue to rise in 2015.
    The 32 members of the task force represented State agency 
heads, the Office of the Attorney General, judges, law 
enforcement offices, physicians, pharmacists, providers of 
substance abuse treatment, individuals in recovery, and parents 
whose children had died from overdose.
    The task force met five times to gather in-depth 
information from experts and to discuss recommendations from 
the five work groups, which met numerous times between the task 
force meetings. In addition to the task force members, the work 
groups also included subject matter experts and individuals who 
had day-to-day knowledge of the issues being explored. Work 
groups focused on education, treatment, storage and disposal, 
data and monitoring, and enforcement, and at the conclusion of 
the task force, 51 recommendations had been adopted for 
consideration by the Governor.
    In the 2015 session of the General Assembly, when the task 
force had only met twice, four of its initiatives were enacted 
into law, and we are hopeful that many of the final 
recommendations will be enacted in the 2016 session.
    Today, I want to share with you some of the most relevant 
initiatives and recommendations resulting from the task force 
and how they tie in with legislation that Senator Kaine has 
introduced.
    When the task force began, Virginia had implemented a pilot 
program to train laypeople to use naloxone, a medication that 
you have heard about already. It reverses the effects of opioid 
overdose. The pilot had focused on two areas of Virginia that 
were most affected at the time, the very rural area of 
Southwest Virginia that borders North Carolina, Tennessee, 
Kentucky, and West Virginia, and the metropolitan area of 
Richmond.
    With the backing of the task force, this project, called 
REVIVE!, went statewide last April. In addition to legislation, 
this legislation permitted law enforcement and firefighters who 
had been trained to carry the medication with them, as they are 
often the first to encounter an overdose victim. Furthermore, 
to increase access to the medication, which could previously be 
obtained only with a prescription, pharmacists were empowered 
to dispense the medication if they have a collaborative 
practice agreement with a prescriber similar to that which 
enables them to administer the flu shot and other vaccines.
    I want to take this opportunity to personally thank you, 
Senator Kaine, for your support of REVIVE! and for the 
distribution of naloxone. In addition to personally being 
trained to use naloxone, Senator Kaine is sponsoring S. 2256, 
which, if enacted, would include training for prescribers in 
co-prescribing naloxone whenever opioid pain medication is 
prescribed. While there are legitimate needs for strong pain 
medications, co-prescribing naloxone can reduce the possibility 
of accidental overdose by the patient, who may accidentally 
take too much medication, or who takes a combination of 
medications that make the effects of the pain medication 
stronger than intended. Naloxone can also reduce accidental 
overdose that results from curious children confusing brightly 
colored pills with candy or risk-taking adolescents who 
impulsively experiment with their family members' medicine.
    Senator Kaine's legislation also supports prescribers being 
trained in appropriate guidelines for the use of opioid pain 
medications, pain management, identification of addiction, 
referral to treatment, and proper methods of disposal. These 
practices are encompassed in an evidence-based practice known 
by the acronym SBIRT, which stands for screening, brief 
intervention, and referral to treatment, endorsed by the World 
Health Organization and the Substance Abuse and Mental Health 
Services Administration and widely discussed in both the 
education and treatment work groups of the task force in their 
recommendations for expanded education for physicians.
    Task force staff have already begun having conversations 
with medical schools in the State about what and how they are 
teaching their students about addiction and pain management so 
that they are able to provide the best medical care possible 
and prevent individuals from slipping into abusive medication 
that could develop into a serious and life-threatening problem. 
This gives them the tools to use in the unfortunate instance 
when addiction does occur.
    Another major theme of the task force was increased use of 
the state's Prescription Drug Monitoring Program, which is a 
data base of all the prescriptions for medications that are at 
high risk for abuse that are filled in the State. The idea is 
that before writing a prescription for a medication that has 
high potential for abuse, such as an opioid pain medication or 
some medications that help individuals to sleep or reduce 
anxiety, a prescriber would check this data base to see if the 
patient had recently had another prescription for a similar 
type of drug filled. If the prescriber found that was the case, 
he or she could discuss this with the patient. In addition, 
pharmacists can also check this data base when they fill the 
prescription and either discuss it with the patient or notify 
the physician. This kind of check can help physicians and 
pharmacists work together to coordinate patient care, help 
identify potential problems, and prevent dangerous situations 
and potential overdoses.
    The task force was successful in getting legislation passed 
that requires all prescribers and dispensers to register to use 
the Prescription Monitoring Program and protects the data in 
the program from use in a civil suit, such as a divorce or a 
child custody case.
    Task force sponsored legislation was also enacted that 
requires hospice facilities to notify the pharmacy of record 
when a patient dies so that a relative of the decedent cannot 
fill a prescription for a pain medication that would then be 
misused.
    Legislation also passed that refines the types of 
information collected and provided by the Prescription 
Monitoring Program, requires pharmacists to report dispensing 
of medication more frequently, and gives the Prescription 
Monitoring Program authority to send reports to enforcement 
authorities when needed.
    Senator Kaine's legislation, S. 1913, Stopping Medication 
Abuse and Protecting Seniors Act of 2015, also seeks to prevent 
abuse of prescription medication by establishing a drug 
management program for Medicare beneficiaries who are at risk 
of abusing their medications. This legislation would also 
utilize the same SBIRT model I previously described to assist 
at-risk individuals in getting treatment and would limit the 
number of pharmacies where the person could use his or her 
Medicare benefits to pay for prescriptions, thus reducing 
opportunities for possible misuse.
    The task force also recognized the significant role that 
treatment plays and the resources that are necessary to support 
a robust system of care. The 2015 session of the General 
Assembly passed legislation that requires health insurance 
plans operating in Virginia to comply with the Mental Health 
Parity and Addiction Equity Act passed by Congress in 2008. 
This gives the State the power to enforce the legislation 
without having to wait for Federal enforcement to occur. We are 
currently working with the Bureau of Insurance to develop 
methods of measuring compliance and developing an annual 
report. This will also reduce discrimination and stigma often 
experienced by individuals who develop addiction, and it will 
help them access care using the resources they have already 
paid for, thus reducing reliance on public sector resources.
    In addition, the task force recommended that Virginia's 
Medicaid benefits for treating substance abuse and addiction be 
expanded to support a more extensive range of services, and a 
budget request has been submitted to support this action.
    In closing, I want to reiterate that although the task 
force is no longer meeting, its recommendations are providing a 
blueprint for action that will serve Virginians well for years 
to come, and we are so pleased to support Senator Kaine's 
legislation at the Federal level, which is congruent with these 
strategies, and again, I very much appreciate the opportunity 
to represent the work of the task force and I am happy to 
answer any questions.
    Senator Kaine. Thank you, Director Randall, and thank you 
to all the witnesses who testified.
    This hearing, if you came and watched a hearing in the 
Dirksen Building downtown, it would be exactly like this. We 
have witnesses offer testimony, usually that is submitted as 
written testimony, and then we ask them questions, and so I am 
going to ask these witnesses questions, probably for about 50 
minutes or so.
    We are scheduled to stop at 12:30. I do not have to leave 
at 12:30. I have another 15 minutes or so before I have to go, 
so what I will do for the folks who have attended to watch 
this, I will interact with some of you, because you may have 
questions or suggestions that we would like to hear, as well, 
but for the next 50 minutes, we will focus on the witnesses and 
I will kind of go in the order in which you testified, although 
there is some overlap in the testimony, so I may ask two of you 
at a time, and if one of you want to weigh in to answer a 
question I direct to somebody else, please feel free to do 
that, too.
    I am going to start with General Herring, and actually 
Director Randall was touching upon this issue, too, so maybe 
first General Herring, and Director Randall might want to talk 
about it. Talk about the Prescription Drug Monitoring Program, 
because I think that is a good model, and in particular, how 
voluntary is it and should it be more--you know, how many of 
our health care providers participate in it and how many do 
not? Would it be better if the degree of participation were 
higher? Is it sufficient to have different states do their own 
programs, or does that lead to kind of gaps where, especially 
in communities that are near State lines, people can go back 
and forth? Talk a little bit about the current program and how 
you think it could be strengthened. First, to General Herring.
    Mr. Herring. Thank you, and definitely, the Prescription 
Monitoring Program is another tool that I think could be used 
in a much more powerful way to hold both patients and 
prescribers accountable for the number of opioids being made 
available, and Senator, you probably remember a little bit 
about the program from your time in State government.
    In Virginia, we now have mandatory registration for 
prescribers and pharmacists, and that has resulted in a more 
robust registration. It is up from 26,000 to now about 70,000, 
but it has not resulted in more robust usage. The current query 
rate is about 9 percent. More than 8,600 practitioners have 
written prescriptions for covered drugs but never queried the 
data base, and there were 121 practitioners who wrote more than 
1,000 covered prescriptions but never queried the PMP at all.
    The Prescription Monitoring Program can be a really 
valuable tool to combat doctor shopping or even to identify 
practitioners that might be prescribing opioids in a 
potentially dangerous way, but it has to be used and it has to 
be accessible.
    There are some bills in the legislature this year to 
strengthen the PMP, to get more folks using it. I think access 
for some of the public health assistance providers, like 
Medicaid and Medicare, could be valuable. If the public is 
going to be paying for health care services, then it makes 
sense that the agencies running those programs should be able 
to find out whether its participants are showing signs of 
addiction or if a provider is engaging in potentially dangerous 
behavior.
    Senator Kaine. Can I ask you one followup, just to make 
sure I understood your answer, so when you say we have gone 
from 26,000 registrations to 70,000, that is folks are being 
registered in the system who are the recipients of opioid 
prescriptions, so when there is an initial prescription, is 
that the number that are being registered, but the physicians 
are not checking to see before they offer that?
    Mr. Herring. These are prescribers----
    Senator Kaine. Oh, these are prescribers.
    Mr. Herring [continuing]. who are registering to use the 
system, but the number of those who are registered to use it 
has gone up, but the query rate is still very low----
    Senator Kaine. Very, very low.
    Mr. Herring [continuing]. and they are not--the prescribers 
are not using it as much as I think they could.
    Senator Kaine. Okay. That is very helpful testimony.
    Director Randall, would you like to further----
    Ms. Randall. Well, I support what General Herring said in 
terms of the issue of lack of use. I think that there perhaps 
could be considered some mandatory checks, and I also think 
that physicians are allowed to write very large prescriptions, 
large numbers of prescriptions, for instance.
    I had a relative who went in with a sprained ankle. She 
sprained it a week before. It was still hurting her. She went 
just to have it checked. It was not broken, it was just 
sprained, and she walked out with 30 hydrocodone, which she 
really did not need.
    I have concerns that prescribers are writing--are able to 
write for such a large number of these pills when maybe five 
are enough, you know, so I think that is something that also 
should be considered by the General Assembly.
    Senator Kaine. Could I ask, just following up on this, 
because I think this is a fascinating question, why would 
prescribers register but then not query? Is it complicated? 
Does it take too long to get an answer back? What can you 
determine in your discussions with prescribers about the low 
query rate?
    Mr. Herring. Well, Mellie may have more information on the 
hurdles to getting prescribers to use it more. It may be a 
factor of time, or it could be that as we continue to inform, 
really, the medical community about these issues and how many 
people are developing dependencies and addiction from 
prescription pain killers, that more prescribers will 
understand the importance of checking it and--everybody is 
pressed for time. We want to try to make improvements in the 
efficiency of the medical system, but at the same time, this is 
something that I think has the potential to help save a lot of 
lives and prevent a lot of addiction if the Prescription 
Monitoring Program is used more.
    Senator Kaine. Other comments on that particular question? 
Yes.
    Dr. Neuhausen. I would love to speak from the provider 
perspective. I actually serve on the Board of the Virginia 
Academy of Family Physicians, where there has been very active 
debate about the PMP legislation currently under consideration 
in Virginia. The General Assembly does have a Senate bill they 
are debating that would require all providers to check the PMP 
if they are writing an opioid prescription for more than 14 
days or a benzodiazepine prescription for more than 30 days, 
and that would address what Attorney General Herring raised, 
where physicians would actually have to log in and check before 
signing that script, but what I have heard from my colleagues--
in my practice, because we serve a large Medicaid uninsured 
population and a high-risk population, we have--all the 
physicians are registered. It is very simple to register for 
the PMP. The issue is, you have to log out of--you have your 
electronic medical record. You have to go to a separate 
website, log in, remember your password, pull up the report, go 
through it, which can take five to 10 minutes, and a lot of 
physicians that have a 15-minute visit, if you are a primary 
care physician, that seems very burdensome.
    In my clinic, we have dealt with it by making all the 
nurses our proxies, so the nurses pull up the PMP and share the 
report, and I know that physicians are talking with the 
Director of Virginia's PMP, Ralph Orr, about making it easy to 
have any member of your clinic staff be able to just access and 
pull up the report.
    I mean, I firmly believe that all physicians should be 
checking the PMP before ever writing an opioid script. It is my 
practice. It is my colleagues' practice. I do think a couple 
policy solutions that would overcome some of the physician 
resistance, because doctors are stressed and are seeing 25, 30 
patients a day. If you could arrange funding so the PMP uploads 
automatically into our electronic medical record, so you can 
just click a button and it pulls up--one doctor has figured out 
how to do that with EPIC--that would make it much easier, just 
a click of a button.
    Washington State did that. They had an ER system, and when 
they were able--physicians were able to just click a button and 
look--they want to look, it is just they do not want to take 
the time--they showed a dramatic, I think, 30 to 40 percent 
decrease in opioid scripts written in Washington State just 
with having the PMP available, and then you also could--and 
physicians have actually requested that the PMP proactively 
send reports to doctors saying, these are your high-risk 
patients that are multiple doctor shopping and multiple 
pharmacies. These are patients who have dangerous medications, 
maybe a benzodiazepine and an opioid.
    I think that just making it easier for physicians, they 
would be really willing to do this, because I think there is 
increasing awareness that this is an epidemic and doctors have 
played a role in creating it and need to help address the 
epidemic.
    Senator Kaine. I am going to come back to Attorney General 
Herring. Those are very good suggestions, and so to kind of 
switch the topic for a minute, just in terms of the magnitude 
of the problem, this hearing today is just focused really on 
kind of a narrow slice of the program, which is the focus 
really is, from the Aging Committee's standpoint, the effect of 
opioids on our seniors, and we have heard broader testimony 
because it is a broader problem, but we could have had a 
hearing on looking at law enforcement professionals in the 
room, and the state's chief law enforcement official. We could 
have a hearing just on the law enforcement side of this and we 
would have had as many or more witnesses.
    Talk a little bit about, in the average court docket in a 
Virginia county or city, the percentage of cases, whether it is 
people engaged in thefts and robberies trying to get things 
that they can use to sell to get drugs, or the persistence of 
these issues as affects domestic violence issues, or as it 
affects automobile accidents. We could have a whole separate 
hearing on this, and as Attorney General, you must see the 
ramifications of this problem over on the civil and criminal 
justice side, as well.
    Mr. Herring. Well, let me answer your question this way, by 
starting to--by telling you a little bit about how I began to 
see how serious a problem this was.
    Almost immediately after taking office, one of the very 
first things I did was to go on a public safety tour, and we 
covered 2,500 miles in a 2-week period. We did 22 local and 
regional meetings with local law enforcement, and I did that 
because I wanted to hear directly from them what were the law 
enforcement challenges, what were the public safety challenges 
in your locality and what could I do as Attorney General to 
help.
    We had over 60 different agencies represented from around 
the State in those meetings. I was really struck by how many 
told me heroin and prescription drug abuse was a problem in 
their areas, a significant problem and getting worse. I think 
three-quarters of the agencies told me that. That was in 
February and March 2014.
    On the heels of that, I was up in Northern Virginia, in 
Loudoun, at a Fraternal Order of Police event and a woman came 
up to me, thanked me for being there, introduced herself, and 
she said, ``I wanted to talk to you to let you know that my 
husband and I have lost our daughter to a heroin overdose just 
a month earlier.'' This was a law enforcement family, so we 
talked about her daughter for a while. She was in her early 
20's. They did not know she was using, but like so many 
families, she said that they are struggling--you know, they 
never thought it would happen to them or to their family, 
anyone in their family, and she looked me right in the eye and 
she said, ``Do not let this happen to another child in 
Virginia.'' That is when I committed to myself, after hearing 
from three-quarters of the law enforcement agencies I spoke to 
out of the 60 that were represented about how serious a problem 
this was, and then hearing directly from someone who was 
affected in that way, that we had to do more, and also in those 
meetings, they told me about how there is a rise in theft and 
other types of crime because so often there is that progression 
that we have heard about, starting perhaps with an accident or 
a surgery where prescription pain killers are prescribed, and 
then prescriptions renewed a couple of times until the 
prescriptions run out. Then they look for them out on the black 
market on the street and in time cannot afford that habit, slip 
to--or cannot afford the prescription pain killers out on the 
street, switch to heroin, and they will steal in order to help 
support that habit, so there is a lot of other spillover crime.
    One other point I would mention, though, is that while 
there are law enforcement components to this issue, and we have 
stepped up our prosecutions and are going to continue to go 
after the dealers and the traffickers, most law enforcement 
that I speak to recognize that it is also a public health issue 
as much as it is law enforcement and that they are working in 
their community on prevention, education, and treatment, and if 
we are ever going to get this problem turned around, we have to 
have robust components for those kinds of programs, prevention 
and education and treatment.
    Senator Kaine. Thank you.
    I want to ask a question that sort of--I think the answer 
should be directed to Attorney General Herring and me, but it 
really stems from something that Lisa talked about, the need 
for family education, so one of the themes of the testimony of 
all of you is to educate prescribers, and that is very 
important and consistently, and there is much that can be done 
about that within the profession, et cetera, but how about the 
education of family members?
    Ms. Wilkins, I am going to ask you this question first and 
then maybe all of you give advice to those of us who are in 
kind of the elected official side. What should we be doing to 
educate family members and citizens? As your youngsters were 
being prescribed these medications for an auto accident, for a 
bad dog bite, I am just curious, how much warning did you get 
right at that time of prescription, hey, this is, like, really 
short-term, but be careful about this, or----
    Ms. Wilkins. None.
    Senator Kaine [continuing]. did you feel like you were 
educated well about the risks?
    Ms. Wilkins. I got absolutely no information. Keep in mind, 
my youngest is 26 now. Chip would be 28, so this has been many, 
many years ago, but no, we go no information about how 
dangerous those drugs were. I got bottles of them, you know, 
30, 60 in a bottle, and refills without question.
    Senator Kaine. It sounds like, then, with respect to your 
testimony about your mother, that by the time she was being 
prescribed these drugs, either the prescriber was educating 
more or you were asking tougher questions and really engaged in 
the management----
    Ms. Wilkins. Right.
    Senator Kaine [continuing]. of that prescription, so talk 
about that a little bit.
    Ms. Wilkins. I was asking tougher questions, still did not 
know, still did not have a clue I had a child in my house using 
heroin. It was seeing the effects of the opiates on her when 
she would get pain medication. My mother was partially disabled 
from a stroke. She used a wheelchair for safety reasons, but 
she could get up and move around with a cane. She would get 
very shaky. She would get violently ill and unable to get to 
the bathroom quickly, just different side effects that I saw 
when they would give her prescriptions.
    Senator Kaine. Well, then, so----
    Ms. Wilkins. I would start to say, no. No.
    Senator Kaine. Well, let me ask this then----
    Ms. Wilkins. We do not want them.
    Senator Kaine [continuing]. to all of you, and again, this 
is more for Generally Herring and me to take this back. If we 
are focusing on family and patient education and we are 
particularly focused on patients and the families of patients 
who are seniors, what are good educational strategies that you 
would suggest to us, you know, either the places where we ought 
to be doing the education or the kind of education that would 
have the greatest impact on seniors and their families, and I 
will just open that to all of you.
    Yes, please.
    Ms. Wilkins. I would actually like to continue on that.
    Senator Kaine. Yes, please.
    Ms. Wilkins. She mentioned only having 15 minutes with a 
patient. My mother's doctor was the most patient man on the 
face of the earth. He spent--he would spend 20, 30 minutes with 
us answering questions, and I think it starts with the doctors. 
There is a trust relationship there. There is a trust 
relationship there, and I know this is a very complicated 
issue, but it behooves them to move quickly through their 
patients through the day, but we have lost that ability to 
build those relationships and I think that is key.
    The freedom to talk to the family members. He would signal 
me. We would step out in the office. We would talk about risks.
    He would ask me if what she was saying was my perception. 
Was it really that difficult? Again, you get back to that risk-
benefit way that you weigh your care.
    Senator Kaine. I cannot remember, Ms. Wilkins, if it was 
your testimony or one of the other witnesses, that often the 
patient's perception----
    Ms. Wilkins. Yes.
    Senator Kaine [continuing]. is so very different than a 
family member's perception when we are in this area, and if a 
caregiver does not understand the big picture, then they may 
focus on the wrong things.
    Director Randall.
    Ms. Randall. One of the things that the task force became 
very aware of and spent a lot of time talking about was 
prescriber education, and we really became aware that in 
medical training, routine medical training, physicians and 
other prescribers get very little training about actual pain 
management and very little training--less than 8 hours in 4 
years--on addiction, and so, the education part of the task 
force really laid out a very specific plan to work with the 
medical schools in Virginia to see what they are providing and 
how it can be enhanced, and we are actually working with some 
assistance from the Substance Abuse and Mental Health Services 
Administration in this regard, as well.
    I think that, you know, for the physicians that are already 
out there, though, there needs to be some continued continuing 
education, and I know Dr. Neuhausen is well aware of this and 
can speak to this well. There has been a lot of debate back and 
forth about when does provider education become mandatory? When 
does the subject matter become mandatory? How do you engage 
prescribers in education about pain management and about 
identifying addiction and learning how to treat it?
    Senator Kaine. Yes, please, Dr. Neuhausen.
    Dr. Neuhausen. I would like to add to those comments. We 
have an entire generation of doctors that were not trained 
appropriately, that were mistrained. I remember in medical 
school in the early 2000's, I was at Emory in Atlanta and we 
were taught that opioids were safe. There were very few risks. 
Do not be afraid to give these medicines. Pain is the fifth 
vital sign. You need to treat pain appropriately.
    Senator Kaine. You are saying, not only--you are saying 
folks were not just not trained, in some instances, they really 
were mistrained.
    Dr. Neuhausen. Yes, that is exactly what happened, so we--
and even now, I precept third year VCU medical students at my 
clinic at Hayes E. Willis and I always ask them, you know, we 
know that 25 percent of our patients have substance abuse, 50 
percent have chronic pain, many have opioid addiction, and I 
always ask them, have you received any addiction training, and 
they look at me and say, ``No.'' I mean, they may have gotten a 
tiny bit and it just did not stick.
    We currently are--and it is not just VCU, it is the vast 
majority of medical schools, so I agree, it is kind of, I 
think, there is a two-fold. I think we do have to reach--the 
best time is to reach doctors in training, pharmacists, nurses. 
It needs to be interprofessional. VCU actually just applied for 
the SBIRT training grant, the substance abuse screening that 
Director Randall mentioned. They applied to SAMHSA for a grant 
that would be nearly a million dollars over 3 years to train 
all VCU medical students, all nurse practitioner students, and 
all primary care psychology students, to have mandatory 
required training, not just a lecture, but where they would 
actually work with a standardized patient, an actor who acts 
out having substance abuse, and would get feedback, and then 
they would go to a low-income senior nursing home--a low-rise 
apartment building, primarily African American, called Dominion 
Place in Richmond and actually interact and screen patients.
    Senator Kaine. In my former City Council district.
    Dr. Neuhausen. Yes, so you know Dominion Place well, so 
and, I think it requires that kind of training, not just the 
lecture, but the practical practicing with a standardized 
patient and then practicing with a real patient, so VCU should 
find out soon. The principal investigator on that is Dr. Pablo 
Bedoya.
    That would be a great step, and then that grant would also 
offer optional training, continuing medical education, to the 
practitioners. That is the second pathway. You have all these 
practitioners out there who are mistrained who need to have the 
education, and once you educate the physicians--and also, I 
mean, we need to have alert systems where physicians--in an 
ideal world, physicians would find out if their patients 
overdosed. They would get a real-time alert saying their 
patient had a non-fatal overdose and they could examine what 
happened, because right now, there is actually a study in a 
recent journal showing that 80 percent of patients who had a 
non-fatal opioid overdose went back and got more opioids from 
their--from another doctor.
    Senator Kaine. Eighty?
    Dr. Neuhausen. Eighty percent went back and got more.
    Senator Kaine. Eighty percent of patients who had a non-
fatal overdose were able to go back and get additional opioids 
prescribed by their caregiver.
    Dr. Neuhausen. Right, because their prescriber had no idea 
they had overdosed. If a physician knew, they would never write 
another prescription for that patient.
    Senator Kaine. Right.
    Dr. Neuhausen. I think once--as Lisa pointed out, I think 
once you educate the physicians, they can have those 
conversations with patients. I, honestly--we now know that 
children who take opioids when they are young, it imprints on 
their brain and--there is emerging evidence that it likely 
imprints and they are at higher risk for addiction later on, so 
I would personally never let a physician give an opioid to my 
daughter unless it were, you know, no other medication worked, 
there was no other option. I think parents need to ask really 
hard questions. Does my child actually need this medication?
    Senator Kaine. This is--many of us in the Senate have been 
really focused on the FDA approval of certain opioid 
prescription medicines for young people and been highly, highly 
critical of that, so that is an issue that is kind of a little 
off the main topic here, but it is connected to it.
    I want to ask Ms. Terry a couple of questions. You touched 
upon a few themes that became common, but you were the one to 
kind of bring it up in a very good way, and that was the CDC 
prescription guidelines and then this question of oversupply.
    Let me go with the oversupply first. My wife two Good 
Fridays ago fell off our back porch and broke and dislocated 
her shoulder, and so she had to get both it reset and pinned 
back together at St. Mary's Hospital in Richmond, and they gave 
her a massive prescription in terms of opioids, and she used 
about a day and a half of it and did not like it. Then it just 
sat in our prescription cabinet until we participated in a drug 
take-back earlier--I guess late in 2015.
    What drives this sort of over-prescription? I guess there 
are different ways to describe over-prescription, and that is 
the dosage is too high, or the number of pills that somebody 
gets is just too much. Talk a little bit about that problem, 
because you guys at the NSC, with your Injury Facts Report, do 
such a good job of really giving information to us about all 
kinds of conditions, but talk a little more about that problem.
    Ms. Terry. I think it is exactly what Dr. Neuhausen 
described of doctors were trained when this fifth vital sign of 
pain started being put into use that these were okay 
medications to use and that they were the Cadillac of pain 
treatment, and doctors who give these have no, for the vast 
majority of them, have no ill intent. They want to try to help 
their patients and treat the pain appropriately, but there is 
this lack of education and that is where we at NSC have said, 
for those doctors who are going to prescribe controlled 
substances, they need to take another step and get further 
education before the DEA grants them a license. Some states 
have already taken that step, but really, it should be a 
national requirement, because there needs to be a reset, and in 
the full testimony that I submitted, it has a graph on there 
that was done by Cochrane Reviews of effective pain relief and 
it shows that the opioids are not as effective as over-the-
counter medications, and in fact, the most effective pain 
relief was one acetaminophen and one ibuprofen taken together 
provided the best pain relief for patients, and so, that reset 
is needed.
    Senator Kaine. That, I guess, is one of the reasons to 
segue to the next topic. You talked about, and others, too, 
your strong support for the CDC prescriber guidelines. Now, let 
me make a statement, but correct me if I get this a little bit 
wrong.
    The CDC has had in process guidelines for the prescription 
of opioids for some time and were on the verge of releasing it. 
It has become controversial. There are some who are asking that 
they not release the guidelines, but my understanding is these 
are not mandates. These are not legal requirements, but they 
are sort of best practices with respect to the prescription of 
opioid medications that would be put out to the medical 
community at large so that they can, in fact, be educated and, 
hopefully, know when and when not to prescribe opioids.
    Is that generally kind of a fair description of the status 
of this discussion about the CDC guidelines at this point?
    Ms. Terry. Yes, sir, and it is exactly as you described it. 
It does not mean that people are going to be cutoff from their 
prescriptions, and for those who are cancer patients who may be 
taking these and it is giving effective relief, you know, they 
just need to have a conversation with their doctor.
    My understanding, too, is that some doctors really want 
these guidelines, because they are having people come into 
their offices demanding these types of medications, so it would 
give them something to fall back on, too, as, look, the CDC is 
advocating this as the best prescribing guidelines for the type 
of pain that you are experiencing.
    Senator Kaine. You talked a little bit about the take-back 
days. Could you repeat that one statistic that you used about 
the last take-back day, how much medicine out of people's drug 
cabinets was returned on this take-back day?
    Ms. Terry. Sure. This last October, it was 350 tons of 
unused medications, and that is not just opioids, but a variety 
of things, and I did not really ever know that these existed 
until a few years ago, and it was right after my mother had 
passed away. I found out this was happening and we had unused 
medications at my house, and thank goodness I found out about 
it and was able to take those to the local sheriff's office to 
drop those off.
    Senator Kaine. It is a very, very significant challenge.
    I would encourage, for those who are here, this Injury 
Facts Report that the NSC does every year is a great source of 
data about this and about all kinds of other health issues in 
the country and I would encourage people to check it out.
    General Herring.
    Mr. Herring. Senator, I just wanted to add one more thing 
on the drug take-backs. Our office does work closely with the 
DEA and the U.S. Attorney's Offices in promoting those, so in 
addition to the general education that is needed about opioids 
and the risk of addiction, promoting those drug take-back days 
are extremely important, and also, some other things that our 
office is doing that are more senior-specific involve reaching 
out into the community. One of the changes that I have made is 
to really try to push our office's services out around the 
State. We have got some really talented people in our office 
and they should not all just be holed up in Richmond, so I want 
to point out that Michele Leith is our Regional Outreach 
Coordinator here in Northern Virginia, and we work very closely 
with local law enforcement and the senior community on programs 
like TRIAD, where we are helping to inform seniors about how to 
stay safe from crimes and other things but that dovetails 
nicely with education about some of these issues, and we help 
provide prescription drug lockboxes and those types of things 
to help make sure that drugs that may be in the medicine 
cabinet do not get into the wrong hands.
    Senator Kaine. Dr. Neuhausen, I wanted to talk to you. You 
were not the only person who talked about this, but you led 
your testimony with the story of a patient who, you know, 
because of consequences of opioid use, was maybe a little 
groggy and then had a fall, and then the fall led to a foot 
injury that did not heal, and then that led to more opioid use.
    I think one of the issues that I had not focused on so much 
until your testimony today is the consequences of opioids on 
things like falls, or heart risk, or other risk to organs. Talk 
a little bit about that, because I think that is an important 
set of consequences to understand as we grapple with this issue 
with seniors.
    Dr. Neuhausen. Sure, so some of the most common side 
effects, other, of course, than the non-intentional overdose, 
opioids can cause sleep breathing disorders, of course, 
respiratory depression, respiratory failure in sleep. That is 
when overdoses usually happen. They can also cause irregular 
heart rhythms. They can cause infertility. They can also 
cause--very often cause confusion, dizziness, and that--as well 
as kind of impaired perception--and that is what often leads to 
the falls, and we have seen increases in ER visits for falls, 
which then cause fractures, particularly among the elderly 
linked to opioid use, and once----
    Senator Kaine. Falls are such a common health problem for 
seniors. I have a 90-year-old mother-in-law who fell 2 days 
before Christmas and was in the hospital for a fall. It is a 
very common health problem for seniors, so anything that would 
exacerbate that problem, obviously, we need to watch pretty 
carefully.
    Dr. Neuhausen. Exactly, and falls can also be devastating 
for seniors. I mean, a hip fracture is often kind of very 
difficult to recover from, and then, particularly because of 
the physiology of the elderly, often their kidney and liver 
function is somewhat impaired, which then causes the opioid 
medicines to stay in the body for longer, which then increases 
the risk of overdosing, because lower doses are much more 
powerful in an elderly person with lower functioning kidneys, 
so that is why you particularly see the elderly at even higher 
risk of all these side effects.
    Senator Kaine. You have done a good bit of research on 
Medicare Part D and opioid drug claims in Virginia under that 
program. Can you talk about that research, the data and what it 
suggests about the scope of opioid prescribing in the 
Commonwealth in the Medicare Part D population.
    Dr. Neuhausen. Sure, and this was really my Office of 
Health Innovation took the data that Centers for Medicare and 
Medicaid Services released showing the Part D opioid 
prescription claims and we mapped it by Virginia county and 
city, and we saw kind of the--I mean, prescription opioids are 
a problem in every county, every zip code, as Attorney General 
Herring mentioned, but we saw particular hot spots in Northern 
Virginia and Hampton Roads and Metro Richmond, and particularly 
in Southwest Virginia, far Southwest. There were certain 
counties down in far Southwest Virginia where there were four 
times as many Medicare opioid prescriptions as there were 
people living in that county, people of all ages.
    Senator Kaine. Repeat that again. I want to make sure I 
understand.
    Dr. Neuhausen. There were, in certain counties in far 
Southwest Virginia, there are four times as many Medicare 
opioid prescriptions as there are people of all ages living in 
that county.
    Senator Kaine. There would be other opioid prescriptions, 
too, but you are just talking about just the Medicare opioid--
--
    Dr. Neuhausen. Just the Medicare, and that is not even 
looking at commercially insured, Medicaid, and when I--yes, and 
our denominator is all people, not just the elderly. When you 
think about that tsunami of pills in these small counties, I 
mean, to me, that was just a really terrifying statistic.
    Senator Kaine. Is that research that you have discussed, is 
that published research?
    Dr. Neuhausen. There is a--on the Centers for Medicare and 
Medicaid Services, there is a link and you can map your county 
and your State. This is all publicly available through CMS, and 
then my office kind of created more specific Virginia maps 
which we would be happy to post on the website.
    Senator Kaine. If you could. I have the capacity to ask 
questions for the record and keep the hearing open so it could 
be submitted. I would like to have that report with the 
Virginia specific data and have it submitted in the record of 
this hearing. If you have no problem with that, I think that 
could be very helpful.
    Dr. Neuhausen. Yes, we would be happy to.
    Senator Kaine. One other question for you, so I am going to 
lean on you as the physician of the group. What about sort of 
the addition of pain as the sort of fifth vital sign and how 
does that kind of factor into the whole culture of over-
prescription we have, because, obviously, we have got to have 
strategies for dealing with pain and it is a very important 
matter that physicians have to query any patient about, but 
sort of adding that to one of the vital signs, and even to how 
physicians and institutions are surveyed--you know, there are 
patient surveys that focus on things like did they help you 
manage your pain--have we hit the balance right in how we look 
at pain management as a kind of definer of this quality of 
medical service?
    Dr. Neuhausen. I think we are far from balanced. I think we 
have kind of gone into the deep end. I hear from colleagues who 
work in urgent care centers or ERs where they are evaluated on 
patient satisfaction, including did you adequately treat the 
patient's pain, and they are terrified to not give the opioid 
prescription because they are worried that the patient will 
give them a zero out of ten, and that will then hurt their 
salary, so I think physicians are actively afraid to say no 
when patients who may already be struggling with addiction 
demand opioids.
    Then I also think, you know, in medical school, you are 
taught to take care of people. You really want to fix people, 
and chronic pain is so hard, because people have the 
expectation that you will give them a magic pill and they will 
feel 100 percent better, and it is tempting for doctors--and if 
a patient comes in--and I have had patients yell at me saying, 
opioids are the only thing that works. Why will you not treat 
my pain? And, I have looked and seen that they have gotten 
opioids from ten doctors in the past year at 14 different 
pharmacies and had to have the long half-hour discussion about 
I am worried about this pattern of addiction, and I have had 
patients--you know, I had a patient storm off and threaten to 
sue me, which, of course, could not happen, but it takes half 
an hour to explain why an opioid is not safe and I will offer 
you all these other medicines that are not addictive that could 
treat your pain, whereas to just write a script takes 5 
minutes.
    I think the combination of the time pressures, the patient 
ratings, and then just doctors are initially altruistic and 
maybe do not understand the harms, have kind of created this 
perfect storm where it is just so much easier to write the 
prescription than it is to say no and have the difficult 
conversation to educate the patient.
    Senator Kaine. Ms. Wilkins, I want to ask you about 
Virginia Change Addiction Now. You talked about your own 
personal experience, but the role of community organizations, 
whether they be nonprofits or whether they be the Area Agencies 
on Aging, can have a big impact--are having a big impact and 
can have a big impact in especially educating family members. 
Talk a little bit about what Virginia Change Addiction Now 
does.
    Ms. Wilkins. We have been active now for about a year and a 
half. We go out into the community. We speak at health fairs. 
We have done two rallies. We did one at the Fairfax Government 
Center in May last year, Steps of Change, and we have speakers. 
Mellie came out and spoke. Don Flattery spoke for us, and we 
have tables with information booths.
    I think we need to better address the needs of the elderly 
community. We just had an International Overdose Awareness Day 
rally in August in Berryville. These are things we need to do. 
We need to get out there. They need to understand what the 
risks. We are trying to reach the kids, but we are overlooking 
our senior citizens. We are not educating them. They think we 
want to cutoff their medicine. They think that we want to make 
it harder for them to get their medicine.
    I just had a call last night from Texas from a woman that 
is a friend of mine. She is 65. She cares for her 90-year-old 
mother. She said, ``Do not throw us under the bus.'' You know, 
it is just so hard to get the medication anymore, and there is 
a balance.
    I do not think they understand the risk and I think we need 
to talk about what that risk is, and it is not just--we are not 
accusing them of being drug seekers. We are not accusing them 
of being junkies. I hate that word.
    Senator Kaine. Mm-hmm.
    Ms. Wilkins. We are trying to prevent them from being 
harmed. We want them to get the best medication available. We 
want them to get the best treatment. There are other 
treatments. The Tylenol with the Advil, I have heard that for 
years. It is wonderful, and there are other----
    Senator Kaine. One of the issues----
    Ms. Wilkins [continuing]. chiropractors, other--there are 
other therapies out there for pain----
    Senator Kaine. Acupuncture. I mean, there are so many 
different----
    Ms. Wilkins. Acupuncture, yes.
    Senator Kaine. The DOD and VA both are really now--because 
I think there has been a culture in those organizations, too, 
that tend to over-rely on opioids, but there is some really 
good work being done now in the DOD and VA systems about, okay, 
there are others. We have used other strategies in the past. 
Maybe they are a little harder. Maybe they are not harder at 
all, but we can move back so there is some good work done.
    Ms. Wilkins. Right.
    Senator Kaine. You touched upon this call that you got from 
a colleague last night. There is still some kind of stigma 
issues, right, that we have to deal with across the range, and 
I would imagine some of the stigma issues would be toughest in 
dealing with the senior population who are getting these 
prescriptions for legitimate medical needs, and the notion that 
there is something wrong with them or we are going to have to 
limit them because it is a big drug epidemic, we are going to 
have to limit what you do, that has got to really strike a 
nerve and make people feel pretty uncomfortable if you do not 
do it the right way.
    Ms. Wilkins. Right, and you talked about the drug take-back 
days. I do not know if Loudoun County has them. In Clarke 
County, we have a box in the Sheriff's department we can just 
take and drop our pills in. We do not have to wait for the 
twice-a-year----
    Senator Kaine. Wait for the DEA.
    Ms. Wilkins [continuing]. DEA days.
    Patients do not know how to do those. They do not know what 
to do with the medications. I found her--one day, I walked into 
the house and it was obvious she had taken something. She was 
confused. She was talking with the tongue, and I said, what did 
you take? Did you--I know you did not drink. What did you take? 
And she said, ``Well, I had a co-Tylenol.'' Where did you get 
that? ``Oh, it is in my dresser drawer. Years, I have had it.'' 
You know, she had a bottle of 30 of them and they were back in 
the back of the dresser.
    We cannot keep those. We need to educate them that you 
cannot--if you did not use them, get rid of them. Not only is 
it a danger for you, it makes you a target for crime.
    Senator Kaine. Other issues on stigma? Yes, Ms. Terry.
    Ms. Terry. Well, the point that you made, Senator, about 
the education, NSC did a survey that we released last year and 
we asked people, have you ever taken an opioid, and we had 
about 29 percent that said yes, and then when we changed the 
question to be, have you ever taken Vicodin, Percocet, 
oxycontin, you had that jump up to over 40 percent said yes, so 
even taking it back to just the basic level of this is an 
opioid. It is oxycontin. It is Percocet. It is Vicodin. That is 
what we are talking about, and just educating people at all age 
levels that that is what this epidemic is about.
    Senator Kaine. Those of you with a historical perspective 
and you are professionals in this area, has there been an 
epidemic of drugs like this where the pathway in has been 
legally prescribed drugs that have a very legitimate medical 
purpose and people are getting them for that reason, but then 
the effects on them are not well enough known and then there is 
this huge consequence that drives a big drug epidemic?
    I am just trying to think, when we were--when Senator 
Herring and I, and I was Governor, were fighting the meth 
problem, that was not--people were not using legal 
methamphetamines and then becoming addicted and going the other 
way. They were trying to make money by selling, so it was a 
very different kind of an epidemic, and I am just kind of 
stepping back and asking, are we dealing with a kind of an 
epidemic that is really different, not just in degree, but 
really in kind, than one we have dealt with before? Doctor.
    Dr. Neuhausen. Thinking back, I mean, I cannot think of 
precedent in this century. I think maybe initially with opium 
from China, and when people got addicted to opium and there 
were not really pain killers----
    Senator Kaine. Right.
    Dr. Neuhausen [continuing], and that was used for pain 
medicine, and then there really was--and morphine was used by 
soldiers in, I think, World War II, and there was some 
addiction to self-medicate, but then, I think there was a big 
backlash where opioids were viewed as very dangerous and very 
few physicians gave them to anyone unless they had cancer and 
you really regulated, and then, I think really in the mid-
1990's with oxycontin being approved, this is very unique, and 
I think that is why it is so hard for physicians, because there 
is not really a precedent for acknowledging that the 
medications that our profession has written has been driving 
this. I mean, I think the equivalent of the opioid epidemic in 
terms of the scope and the number of lives it has touched is 
more like HIV epidemic. I mean, we have more people dying per 
year of opioid and drug overdoses than breast cancer. I mean, 
it is--so, I think, historically, there has not been any 
precedent in this century, and that is part of why this is much 
harder to solve than any epidemic we have had before.
    Senator Kaine. I am going to ask Director Randall one last 
question, and then I am going to ask each of you if you have 
something you want to say to sum up. I will just let you think 
about that while I was asking Director Randall.
    As part of the Governor's task force, you came up with 
recommendations, and some are things the Governor can do or can 
be implemented through the CSBs, but some are things where you 
need legislative support. I want to ask whether in Virginia, in 
Richmond, it is like in D.C. We are divided by partisanship on 
many issues in D.C. This is not one where we are divided by 
partisanship. There is a good working core of Democrats and 
Republicans in both houses. I have heard Speaker Ryan talk 
about it. I have heard President Obama talk about it. The bill 
that I have on the Co-Prescribing Saves Lives, it is Senator 
Shelley Moore Capito, Republican of West Virginia, among the 
cosponsors.
    Is it the same way so far--I know you have legislation 
pending and the General Assembly is in session--but are you 
seeing this as an issue where the partisan divisions that 
sometimes cause us to stumble are not so significant in this 
area?
    Ms. Randall. I am very heartened by how the parties have 
come together to address some of the issues and to take on some 
of the initiatives that have come out of the task force, and 
there have been some pleasant surprises. People who were not on 
the task force who were of the opposite party from the Governor 
have really stepped up to the plate, and when we constructed--
as staff constructing the task force, also, we really wanted to 
make it bipartisan and we were deliberate in thinking about who 
would be good advocacy from both parties.
    For instance, Delegate John O'Bannon, who is also a 
neurologist, Republican, co-chaired the task force with Deputy 
Secretary Jennifer Lee, who is also a physician, so you know, 
there was very good bipartisanship, and here in the General 
Assembly as the bills are making their way through, we are also 
seeing good partisanship as people are really understanding the 
impact on their communities and they are beginning to learn a 
little bit more about the science of addiction and the public 
health aspect of addiction.
    Senator Kaine. Well, if there is a promising sign in the 
midst of all these challenges, the fact that this is not 
politically divisive, at least not in the strict partisan way, 
is a positive sign, so that means that evidence-based 
solutions, we ought to be able to rally around.
    This has been a very, very good hearing and I really 
appreciate the witnesses for coming and I appreciate all of you 
for coming and participating. Again, this testimony will all be 
available online through the Senate Aging Committee, but I 
would like to ask of General Herring, then we will just move 
right across the table, for our witnesses to offer any final 
comments that they choose to.
    Mr. Herring. I would just like to, again, thank you for 
shining a spotlight on this aspect of the heroin and 
prescription drug epidemic that we are facing in Virginia, and 
really not just Virginia, but all over the country, and 
addiction among older Virginians is a group that is often 
overlooked and I think we are, across the country, coalescing 
behind the need for expanding prevention and treatment and 
education, and if we are ever going to get this problem turned 
around, it is going to be with those very robust programs and 
identifying specific strategies that we can turn it around, so 
thank you for shining a spotlight on this.
    Senator Kaine. Thank you for your leadership, and I know 
you have a great team in your office that is working on it, 
too, and I extend my thanks to them, as well, General Herring.
    Director Randall.
    Ms. Randall. I just want to thank you again for this 
opportunity and just encourage anything that we can do to 
answer your questions or to provide any resources, please feel 
free to call upon us.
    Senator Kaine. I will. Thank you, Director Randall.
    Ms. Terry.
    Ms. Terry. This epidemic is really one that is going to 
require a comprehensive approach, and part of that is going to 
include removing the stigma around addiction. Addiction is a 
disease. It is not a character flaw, and so, getting people to 
think about it that way, getting people in treatment who have 
some of these issues and really providing holistic solutions 
here is what is going to be helpful, and thank you for having 
us.
    Senator Kaine. Absolutely. Thank you.
    Dr. Neuhausen.
    Dr. Neuhausen. Thank you, Senator Kaine. This has been a 
really eye-opening hearing and it is wonderful to see so much 
attention paid to this issue.
    I guess I just wanted to end with a very brief story. When 
you had asked earlier about what kind of education is needed 
for caregivers and families, my 91-year-old grandmother, who 
grew up in Clifton, Virginia, was a retired nurse, had an acute 
neck spasm. None of the other medicines we tried worked--
Tylenol, Advil, over-the-counter, so she did get oxycodone. It 
was very effective, but my mom and I--my mom has no medical 
background--very carefully weaned her down and took her, you 
know, down from one pill four times a day, to one pill three 
times a day, to twice a day, and so, I think that family 
members can be really vigilant, and I really encourage patients 
and family members to ask what are the side effects and to push 
for how quickly can I get off this and to get off it quickly 
while treating the pain, because I do think that prevention is 
the first step, and we will need--you know, a lot of these PMP 
solutions are going to keep people from getting addicted, but 
we need treatment so desperately, because just cracking down 
with the PMP, getting rid of the supply, does nothing about the 
millions of Americans already addicted, and that, I think, we 
really need a massive infusion of funding. We need 
comprehensive increases in rates, and we need providers to 
start offering this life-saving treatment.
    Senator Kaine. Excellent. Thank you.
    Ms. Wilkins.
    Ms. Wilkins. Thank you. Thank you for having us here.
    I think education. We need to get the word out and it needs 
to be in a more comprehensive manner, to the providers, to the 
families, and not isolated. This has opened my eyes. Not 
isolated just to the young people, but also to the seniors and 
the impacts it is having on them. The education with the 
doctors, getting that treatment, recognizing that there are 
medications that treat addiction that are scientifically 
evidenced, making that available to people. I think this is 
treatment, treatment, early intervention. To have, whether it 
is an older person or a younger person, come to you and go, I 
have a problem, I need to stop, then they have to wait weeks--
--
    Senator Kaine. Yes.
    Ms. Wilkins [continuing]. weeks to get treatment----
    Senator Kaine. By then, maybe they are over the wanting to 
ask for help right away, or, you know, so----
    Ms. Wilkins. Yes. If you do not act when they ask for help, 
you are setting them up for failure.
    Senator Kaine. You may miss an opportunity.
    Ms. Wilkins. It is going to be deadly.
    Senator Kaine. Well, thank you to you all.
    One formality, which is often when we have hearings, we 
hold the record open for a few days in case the member, like 
me, wants to ask some questions in writing, and I would like to 
hold the record open until Friday at 5. My staff and I will 
kibitz a little bit and we will potentially submit some 
questions. Certainly, Dr. Neuhausen, the Virginia-specific 
extrapolation of the CDC data about Medicare Part D 
prescriptions of opioids in Virginia is something we are 
interested in, but we may think of some other questions, and I 
would just ask your cooperation, and if we do direct questions 
to you, if you can respond within a reasonable time period, I 
would appreciate that, and then, second, to those who attended, 
one thing I would just offer as an encouragement, if you want 
to know more, there are a lot of ways to know more, but one 
great way is the program that Director Randall talked about, 
Virginia's Project REVIVE!, which is a statewide program to 
teach people about the administration of naloxone. I took that 
training in the summer of 2014 in Lebanon, in Russell County, 
Virginia, and it is more than just learning how to administer 
naloxone. It is about the opioid problem and the kind of 
physical challenges it presents, and you learn to administer 
naloxone, which is--those of us, every once in a while, if we 
have learned to administer the Heimlich maneuver or learned 
basic first aid, this is now kind of part of that skill set, 
where you would both learn information that could help you or a 
loved one, but also educate you in ways that you may be able to 
educate others, as well, so I would encourage a very good 
Virginia program, Project REVIVE!, and if you have the 
opportunity to take it, I would encourage you to.
    With that, I thank everybody for attending, and this 
hearing of the Senate Special Committee on Aging is adjourned.
    [Whereupon, at 12:32 p.m., the Committee was adjourned.]

    
      
      
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                                APPENDIX

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                      Prepared Witness Statements

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