[Senate Hearing 114-718]
[From the U.S. Government Publishing Office]


                                                       S. Hrg. 114-718

  OPIOID ABUSE IN AMERICA: FACING THE EPIDEMIC AND EXAMINING SOLUTIONS

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

                                 HEARING

                                 OF THE

                    COMMITTEE ON HEALTH, EDUCATION,
                          LABOR, AND PENSIONS

                          UNITED STATES SENATE

                    ONE HUNDRED FOURTEENTH CONGRESS

                             FIRST SESSION

                                   ON

EXAMINING OPIOID ABUSE IN AMERICA, FOCUSING ON FACING THE EPIDEMIC AND 
                          EXAMINING SOLUTIONS

                               __________

                            DECEMBER 8, 2015

                               __________

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                                Pensions
                                
                                
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          COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS

                  LAMAR ALEXANDER, Tennessee, Chairman

MICHAEL B. ENZI, Wyoming		PATTY MURRAY, Washington
RICHARD BURR, North Carolina		BARBARA A. MIKULSKI, Maryland
JOHNNY ISAKSON, Georgia			BERNARD SANDERS (I), Vermont
RAND PAUL, Kentucky			ROBERT P. CASEY, JR., Pennsylvania
SUSAN COLLINS, Maine			AL FRANKEN, Minnesota
LISA MURKOWSKI, Alaska			MICHAEL F. BENNET, Colorado
MARK KIRK, Illinois			SHELDON WHITEHOUSE, Rhode Island
TIM SCOTT, South Carolina		TAMMY BALDWIN, Wisconsin
ORRIN G. HATCH, Utah			CHRISTOPHER S. MURPHY, Connecticut
PAT ROBERTS, Kansas			ELIZABETH WARREN, Massachusetts
BILL CASSIDY, M.D., Louisiana

                                   

               David P. Cleary, Republican Staff Director

                  Evan Schatz, Minority Staff Director

              John Righter, Minority Deputy Staff Director

                                  (ii)

                            C O N T E N T S

                               __________

                               STATEMENTS

                       TUESDAY, DECEMBER 8, 2015

                                                                   Page

                           Committee Members

Alexander, Hon. Lamar, Chairman, Committee on Health, Education, 
  Labor, and Pensions, opening statement.........................     1
Murray, Hon. Patty, a U.S. Senator from the State of Washington..     2
Collins, Hon. Susan M., a U.S. Senator from the State of Maine...     4
Bennet, Hon. Michael F., a U.S. Senator from the State of 
  Colorado.......................................................     6
Mikulski, Hon. Barbara A., a U.S. Senator from the State of 
  Maryland.......................................................    32
    Prepared statement...........................................    32
Hatch, Hon. Orrin G., a U.S. Senator from the State of Utah......    36
Franken, Hon. Al, a U.S. Senator from the State of Minnesota.....    37
Scott, Hon. Tim, a U.S. Senator from the State of South Carolina.    39
Baldwin, Hon. Tammy, a U.S. Senator from the State of Wisconsin..    41
Cassidy, Hon. Bill, a U.S. Senator from the State of Louisiana...    43
Warren, Hon. Elizabeth, a U.S. Senator from the State of 
  Massachusetts..................................................    44
Casey, Hon. Robert P., Jr., a U.S. Senator from the State of 
  Pennsylvania...................................................    46
    Prepared statement...........................................    46
Whitehouse, Hon. Sheldon, a U.S. Senator from the State of Rhode 
  Island.........................................................    49

                               Witnesses

Wen, Leana, M.D., Baltimore City Health Commissioner, Baltimore, 
  MD.............................................................     7
    Prepared statement...........................................     8
Valuck, Robert, Ph.D., RPh, FNAP, Professor, Department of 
  Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical 
  Science, University of Colorado, Aurora, CO....................    15
    Prepared statement...........................................    17
Spofford, Eric, Chief Executive Officer, Granite House, Derry, 
  NH; New Freedom Academy, Canterbury, NH........................    23
    Prepared statement...........................................    25

                          ADDITIONAL MATERIAL

Statements, articles, publications, letters, etc.:
    Response by Leana Wen, M.D. to questions of:
        Senator Casey............................................    52
        Senator Franken..........................................    54
        Senator Bennet...........................................    57
        Senator Whitehouse.......................................    60
        Senator Warren...........................................    61
    Response by Robert Valuck, Ph.D., RPh, FNAP to questions of:
        Senator Murkowski........................................    62
        Senator Casey............................................    63
        Senator Franken..........................................    63
        Senator Bennet...........................................    64
        Senator Whitehouse.......................................    65
        Senator Warren...........................................    66

                                 (iii)

  

 
  OPIOID ABUSE IN AMERICA: FACING THE EPIDEMIC AND EXAMINING SOLUTIONS

                              ----------                              


                       TUESDAY, DECEMBER 8, 2015

                                       U.S. Senate,
       Committee on Health, Education, Labor, and Pensions,
                                                    Washington, DC.
    The committee met, pursuant to notice, at 10:02 a.m., in 
room SD-430, Dirksen Senate Office Building, Hon. Lamar 
Alexander, chairman of the committee, presiding.
    Present: Senators Alexander, Collins, Scott, Hatch, 
Cassidy, Murray, Mikulski, Casey, Franken, Bennet, Whitehouse, 
Baldwin, Murphy, and Warren.

                 Opening Statement of Senator Alexander

    The Chairman. The Senate Committee on Health, Education, 
Labor, and Pensions will please come to order. Senator Murray 
and I will each have an opening statement, and then we'll 
introduce our panel of witnesses.
    We thank you for being here.
    After our witness testimony, Senators will have 5 minutes 
of questions.
    Today, we're meeting to discuss the growing epidemic in 
this country of opioid abuse and overdose. The term opioid 
includes prescription opioid painkillers, like hydrocodone and 
morphine, and also the illegal drug heroin.
    Some people can become addicted to prescription opioid 
painkillers, and the illegal drug heroin is highly addictive, 
placing people at risk for overdose.
    According to the National Institute on Drug Abuse, 
prescription opioid painkiller abuse may lead to heroin abuse. 
Dr. Tom Frieden, the director of the Center for Disease Control 
and Prevention, said the heroin epidemic is a one-two punch. 
First, a growing number of people are exposed to and become 
addicted to prescription opioid painkillers, which he said 
primes people for heroin addiction later. Then the second punch 
is, accessibility to heroin has increased.
    The number of prescription opioid painkillers prescribed to 
patients in the United States has skyrocketed in the last 25 
years, from 76 million in 1991 to nearly 207 million in 2013. 
Sadly, along with that trend, we've seen a staggering increase 
in overdose deaths in the United States due to prescription 
opioid painkillers, which have more than tripled over the last 
15 years. Additionally, the number of heroin users has doubled 
since 2005 and reached 670,000 in 2012 and continues to trend 
upward, taking more than 8,200 lives in 2013 alone.
    In September, Dr. Frieden came to Knoxville where we hosted 
a roundtable with local physicians, community leaders, and 
public health officials on ways to fight opioid abuse. He said 
then that opioid abuse is a growing epidemic that is gripping 
our country.
    Tennessee ranks near the top of the list for prescription 
drug abuse, which includes opioids, with the third highest rate 
of abuse in the Nation. According to a 2011 survey, more than 
69,000 people in our State were estimated to be addicted to 
prescription opioid painkillers, and more than 1,000 
Tennesseans die each year as a result of drug overdose. The 
State is taking a number of actions to deal with it, including 
dealing with a practice called doctor shopping--those seeking 
prescription opioid painkillers going to multiple doctors.
    At our September roundtable, Dr. Frieden announced that 
Tennessee was one of 16 States to receive funding through the 
CDC, $3.4 million over 4 years, to help the State continue this 
fight. At the roundtable, we heard from Austin Maxwell, a 
father who lost his son to a prescription opioid painkiller 
overdose just days before that son had planned to head to 
college and walk on to practice with the school's football 
team.
    I know I'm not alone in hearing about these challenges. 
Senator Collins has talked about this often. The truth is it 
affects all of our States. Senators Ayotte and Manchin have led 
a group of nine Senators in highlighting the damage of this 
epidemic.
    Last month, the president signed into law the Protecting 
Our Infants Act of 2015, which came out of this committee. 
Senator McConnell, Senator Casey, a member of the committee, 
and Senator Ayotte all worked hard on that. There's a lot of 
interest in addressing this problem, as you can see by the 
number of Senators here today. I look forward to our 
conversation.
    Here's an example of maybe one of the things we can look 
into. In our Knoxville roundtable, Representative Bill Dunn, a 
State representative, told me that the patient satisfaction 
survey from Medicare patients actually has the perverse effect 
of encouraging physicians to overprescribe prescription opioid 
painkillers, because reimbursements for hospitals are based to 
some extent on the score that patients give their doctors about 
how well they're satisfied with their treatment. I talked to 
Secretary Burwell about that. I was glad to see this direct 
response from the administration to a suggestion that came from 
our roundtable in Knoxville.
    This is a complex problem that calls for action by all 
those who have a role in it. We know that recovery from opioid 
abuse can be a long and challenging road. We look forward to 
our witnesses today as they tell us about the challenges they 
face and suggest solutions that we can help with.
    Senator Murray.

                  Opening Statement of Senator Murray

    Senator Murray. Thank you very much, Chairman Alexander.
    To all of our witnesses, thank you for coming today to 
share your expertise.
    The conversation that we're having today could not be more 
important, because the epidemic of opioid abuse is being felt 
across our country. According to the CDC, 44 people die each 
day in the United States from prescription painkillers. The 
Substance Abuse and Mental Health Services Administration 
estimated that in 1 month alone, 4.3 million people use 
prescription painkillers without a medical reason.
    Opioid use is a serious problem in my home State of 
Washington as well. Compared to the early 2000s, University of 
Washington researchers found that drug deaths involving opioids 
have increased 31 percent. Publicy funded inpatient admissions 
for opioid-related treatment have increased 197 percent over 
the same time period.
    Those statistics are deeply disturbing. What's worse is the 
suffering behind those numbers: millions of lives taken 
completely off track, mothers and fathers who worry about the 
late-night calls they might get or what it means if no call 
comes through, and communities across the country that have had 
to do without the contributions of those whom addiction seized.
    As a parent and grandparent and a U.S. Senator, I believe 
the opioid epidemic is a challenge that cannot go unmet. I'm 
really glad that we have the opportunity today to hear from 
some experts, including someone who has lived through 
addiction, who are dedicated to tackling this.
    There are a few key issues related to prevention and 
treatment that I am especially interested in. I believe we need 
to find ways to ensure that opioids are consistently prescribed 
for clinically appropriate reasons. We should make sure that 
patients in pain are able to get the help they need and that 
they are also being treated according to clinical best 
practices. That means taking a close look at prescriber 
guidelines.
    My State of Washington was one of the first to develop 
prescribing guidelines for opioids and has a law in place to 
ensure that these guidelines are regularly updated. This is a 
valuable tool to help prevent unnecessary access and nonmedical 
use.
    I'm also very interested in making sure that when doctors 
prescribe opioids, they have full information about whether 
their patient already has a prescription and how often they 
need refills. There is simply no reason a person struggling 
with addiction should be able to doctor shop and get multiple 
prescriptions. That's not only bad for those suffering from 
opioid abuse, but it also takes time away from true medical 
needs that doctors' offices and emergency rooms need to 
address. My home State has developed a system for tracking the 
use of prescription opioids to crack down on unnecessary 
prescriptions, and I'm looking forward to hearing from our 
witnesses about other best practices in this space.
    In addition to taking action to keep people from becoming 
addicted in the first place, we also need to improve treatment 
and prevent overdose. One important way to do this is to expand 
access to naloxone, which acts to reverse the effects of an 
ongoing overdose. Policies that allow people without medical 
backgrounds to administer naloxone and that make sure this 
treatment is readily available in communities have been shown 
to save lives.
    Dr. Wen, I know that is something that you have been 
focused on in your work, and I'm eager to hear more from you 
about that.
    Access to medication-assisted therapy is another barrier to 
treatment. The most commonly used drug to treat addiction is 
buprenorphine, but providers with the training to prescribe it 
can only treat a certain number of patients. Earlier this fall, 
President Obama announced that the Administration aims to 
increase the number of prescribers in the United States from 
30,000 to 60,000 over the next 3 years. That is an ambitious 
goal, but I believe it would go a long way to making sure that 
when people suffering from substance abuse disorders seek 
treatment, they can get it.
    Tackling this epidemic is not going to be easy, and the 
steps I've laid out are a few of the many that we'll need to 
take in order to do so. I believe they would make a real 
difference for families and communities who are suffering right 
now. The bottom line is that every day that a child loses a 
parent or a parent loses a child to this crisis is a day too 
many.
    I know that my colleagues on both sides of the aisle agree 
with that, and I'm looking forward to working together on ways 
to end this epidemic so that families and communities don't 
have to suffer from more losses. We have seen far too many 
already.
    Thank you again to all of you for joining us, and I'll turn 
it back over to Chairman Alexander.
    The Chairman. Thank you, Senator Murray.
    Before I introduce the witnesses, Senator Murray and I need 
to go to the floor after we hear from the witnesses and ask our 
questions, because we need to speak, and we'll be voting on our 
bill to fix No Child Left Behind, which every member of this 
committee has had some role in. Senator Collins has agreed to 
chair the hearing at that point, and I wanted to call on her 
and see if she has a statement she would like to make at this 
point, and then we'll go to the witnesses.

                      Statement of Senator Collins

    Senator Collins. Thank you very much, Mr. Chairman. I want 
to congratulate both you and Senator Murray on a truly 
outstanding accomplishment on education reform. I look forward 
to supporting your efforts on the floor today.
    In many States, including Maine, the prescription drug 
abuse crisis has also become a heroin crisis, overwhelming our 
communities and families often with tragic consequences. Maine 
has been particularly hard hit by this epidemic. In 2014, there 
were 100 overdose deaths from heroin and other substances. That 
is up from only 16 in 2010.
    In the first half of this year, 63 opioid overdose deaths 
have been reported. In the month of July alone, the city of 
Portland had 14 suspected heroin overdoses, including two 
deaths in 1 day. The number of people seeking treatment in 
Maine for opioid abuse has more than tripled in the past 4 
years.
    Perhaps most tragic is the impact on the most vulnerable in 
our society, the babies born to addicts. In Maine, in the last 
fiscal year, nearly 1,000 babies were born drug and/or alcohol 
addicted, a number which represents 8 percent of all births in 
our State.
    Maine and New Hampshire have the dubious distinction of 
having the most prescriptions per person for long-acting and 
high-dose painkillers, according to the CDC. When those 
prescriptions lead to addiction, the next stop is too often 
heroin. According to a study by the Maine Sunday Telegram, 
international drug cartels and the inner city drug gangs have 
targeted Maine as an emerging and lucrative market for heroin.
    This epidemic is playing out in emergency rooms and county 
jails and on main streets in my State and throughout the 
country. Maine sheriffs tell me that their jails are 
overwhelmed by those struggling with addiction and that they 
cannot arrest their way out of this epidemic. They're not 
designed to take the place of treatment centers, yet sheriffs 
and police chiefs must train their officers to look for signs 
of withdrawal and to monitor mental health status.
    I recently received from a constituent of mine a letter 
detailing his road to addiction, which began in high school as 
a result of football injuries for which he was given oxycodone. 
It was in college when the use of painkillers became a serious 
problem and later led him to use heroin. His letter goes on to 
describe his attempt to treat his depression with painkillers 
and, as he put it, years of chasing the feeling of being 
normal.
    It's so important that our committee is examining this 
serious public health crisis, and I want to commend our leaders 
for doing so. Thank you.
    The Chairman. Thank you, Senator Collins.
    I'll ask Senator Mikulski to introduce our first witness 
and Senator Bennet to introduce our second.
    Senator Mikulski. Thank you, Mr. Chairman, and also good 
luck and thanks to you today for moving the Every Child 
Succeeds Act, and we look forward to voting for it and passing 
it. Most of all, thank you for really working on a bipartisan 
basis to move this legislation.
    We also want to thank you today for continuing this ongoing 
set of hearings on opioid abuse. In Maryland, it is, indeed, a 
public health epidemic and a public health emergency. Close to 
600 people in Maryland died last year of an overdose. Fifty 
percent of those were in Baltimore City. In Baltimore City last 
year, we had 300 people die of a drug overdose. We also had 300 
people shot, usually related to drug gangland type killings, 
some of whom were children who were caught up in street 
massacres that were shot while sitting on their own front 
steps.
    Our Republican Governor says this is a public health 
emergency. No matter what county you go to in Maryland, this 
is, indeed, an epidemic.
    We have one of our rising stars in Maryland, Dr. Leana Wen, 
who is the Health Commissioner in Baltimore City, to come and 
share her experiences and her solutions that are really showing 
results in our city. We're very proud of Dr. Wen. She is the 
head of the Baltimore City Health Commission. One thousand 
people work there, and it handles everything from maternity and 
child health to behavioral and drug addiction issues.
    Since her appointment in 2015, Dr. Wen has led the 
implementation of citywide opiate overdose prevention and 
response plans, including innovative ideas like hot-spotting 
and street outreach teams that she's going to tell you about, 
how she trained police officers and lay people in terms of 
being able to respond to this crisis, and launching a 
significant public health education program.
    She has done an outstanding job there, and during our 
recent uprising, she led the public health recovery efforts, 
ensuring that prescription medications, the legal drugs, were 
in the hands of the senior citizens, the diabetics, the others 
who needed it, and really helped lead. She was like a medical 
FEMA out there during these very difficult days.
    She comes from this background: yes, a brilliant academic 
background, a Rhode scholar, a consultant to the World Health 
Organization, but her hands-on practice started as an emergency 
room doctor. Seeing what all comes into an emergency room, all 
of the trauma, the injury, and the human misery, led her into 
the field of public health and prevention.
    You'll enjoy listening to her, and I think she will give us 
the kind of specific recommendations we need. I'm proud to 
introduce her to the committee as a Baltimore hometown girl.
    The Chairman. Thank you, Senator Mikulski.
    Senator Bennet.

                      Statement of Senator Bennet

    Senator Bennet. Thank you, Mr. Chairman. I also would like 
to lend my congratulations to you and to Senator Murray for the 
reauthorization we're going to have today of the Elementary and 
Secondary School Act. It really was a remarkable 
accomplishment, and I think it has established a standard for 
bipartisan work in the Senate that I hope the rest of the 
committees will be able to live up to. So thank you for that.
    Thanks also for giving me the opportunity to introduce Dr. 
Robert Valuck, who is here from the University of Colorado. At 
the University of Colorado, Dr. Valuck serves as a professor in 
the Department of Clinical Pharmacy. He holds additional 
employments at the Colorado School of Public Health and School 
of Medicine.
    He's also currently the coordinator of the Colorado 
Consortium for Prescription Drug Abuse Prevention. The 
consortium was launched in 2013 to establish a coordinated 
statewide response to reduce the abuse and misuse of 
prescription drugs in our State. It is accomplishing that 
through improvements in education, public outreach, research, 
safe disposal, and treatment.
    Dr. Valuck has been president of the Colorado Prescription 
Drug Abuse Task Force since 2009 and a member since 1998. He 
has authored several articles on the topic of opioid abuse and 
dependence. He received his bachelor's degree in pharmacy from 
the University of Colorado and his master's degree and a Ph.D. 
from the University of Illinois at Chicago.
    Thank you, Dr. Valuck, for being here. We look forward to 
hearing your testimony.
    The Chairman. Thank you, Senator Bennet.
    Our third witness is Eric Spofford. He's the chief 
executive officer of Granite House, a sober living and halfway 
house in Derry, NH, they say, and New Freedom Academy, a 
substance abuse treatment center focusing on young men in 
Canterbury, NH. His perspective is unique. He not only helps 
serve individuals seeking help for addiction, but he's also a 
person in recovery.
    We look forward to your testimony.
    Dr. Wen, we'll start with you, if we may. We'd like to ask 
each of you to try to summarize your remarks in about 5 
minutes, because we have a number of Senators here who would 
like to have a conversation with you about what you've said.
    Dr. Wen.

      STATEMENT OF LEANA WEN, M.D., BALTIMORE CITY HEALTH 
                  COMMISSIONER, BALTIMORE, MD

    Dr. Wen. Chairman Alexander, Ranking Member Murray, and 
members of the committee, thank you for calling this important 
hearing. I'm here today, as Senator Mikulski said, as an ER 
doctor who has treated hundreds of patients who have overdosed 
on opioids. I'm also here as the Health Commissioner of 
Baltimore City, where I have declared the epidemic to be a 
public health emergency.
    I wish to share the three pillars of Baltimore's innovative 
and science-based approach to this issue. Our first pillar is 
to prevent overdose deaths through widespread dissemination of 
the antidote, naloxone. I have used this medication, naloxone, 
hundreds of times, and I've seen how someone who is 
unresponsive and about to die will be walking and talking 
within seconds.
    We have worked hard to break down the barriers to naloxone 
access so that everyone can save a life. This year alone, we 
have trained over 7,000 people, most of whom are lay people. As 
of October 1, I have the authority to write a blanket 
prescription for naloxone to all 620,000 residents in Baltimore 
City. This standing order is one of the single largest efforts 
in the country to achieve widespread naloxone distribution.
    We also began training our police officers, as Senator 
Mikulski mentioned. Initially, there was some resistance from a 
few who did not see medical interventions as part of their job. 
However, in the first month of carrying naloxone, four officers 
have used naloxone to save the lives of our residents. I just 
conducted a training where officers were talking about how 
their duty is to save a life, which is a significant paradigm 
shift and one that we need across the country.
    Naloxone, though, is necessary but not sufficient, because 
we know that addiction is a chronic brain disease, and we are 
just treading water unless we can ensure access to ongoing 
treatment. That's why our second pillar is that we work to 
increase access to on-demand treatment, which includes 
medication-assisted treatment with buprenorphine and methadone 
and long-term recovery support.
    Nationwide, only 11 percent of patients with addiction get 
the treatment that they need. There is no physical ailment for 
which we would find that acceptable. Imagine if I'm saying that 
only 1 in 10 patients with cancer can get chemotherapy. Yet I 
tell my patients seeking addiction treatment that they must 
wait weeks or months. Some will come back to me sooner in the 
ER, maybe with a fatal overdose, because we failed to get them 
help at the time that they asked for it.
    In Baltimore, we are working toward treatment on demand 
with a 24/7 phone line that provides immediate consultation 
with a social worker or addiction counselor; crisis services, 
where an outreach worker will visit the patient in their home; 
and information for families seeking resources. We have also 
secured $3.6 million from our State legislature toward 
establishing a stabilization center, also known as a sobering 
center, which is the first step to our starting a 24/7 urgent 
care for addiction and for mental health.
    In addition, we are training peer recovery specialists, 
people who have a history of addiction themselves, because they 
are the most credible messengers. Not only does it bring jobs 
to individuals who may otherwise have trouble finding 
employment, but our trainees tell me every day that they are 
dealing with their addiction and how thankful they are to serve 
our fellow residents.
    These are the stories we must tell together so that we can 
educate on the true nature of substance addiction, that 
addiction is a disease and that recovery is possible. That's 
why our third pillar is that we provide education to reduce 
stigma and prevent addiction. These efforts are targeted to two 
populations. First is the public. We launched a public 
education campaign, DontDie.org, with bus and billboard ads and 
targeted outreach in churches and neighborhood groups.
    Second is physicians. In 2014, there were 259 million 
opioid prescriptions in this country. That's enough for one 
bottle of opioids for every adult American. I have sent best 
practice letters to every doctor in Baltimore that address the 
risk of addiction and overdose and requires co-prescribing of 
naloxone with opioids.
    Through our three pillars, Baltimore is emerging from being 
the heroin capital to the model of addiction recovery. There is 
much that we have done at the local level, but challenges 
remain. My written testimony provides four specific actions for 
Congress that include, first, ensuring equitable insurance 
coverage for addiction services; second, providing cities and 
States the opportunity to innovate with new models; third, 
monitoring and regulating the rapidly rising price of naloxone; 
fourth, pushing for a national stigma reduction campaign.
    The epidemic of opioid addiction is affecting the entire 
country, and we're all in this together. I thank you for 
calling this important hearing and look forward to working 
together to save lives, help families, and reclaim communities, 
and I'm happy to answer any questions that you may have.
    [The prepared statement of Dr. Wen follows:]
                 Prepared Statement of Leana Wen, M.D.
                                summary
    As an emergency room (ER) doctor, I have witnessed firsthand the 
effects of substance addiction on individuals and families, including 
treating hundreds of patients who have overdosed on opioids. As the 
Health Commissioner of Baltimore City, I work every day with my 
dedicated staff at the Baltimore City Health Department (BCHD) and 
partners across our city to prevent overdose and stem the tide of 
addiction. Our efforts are changing the face of Baltimore from the 
``heroin capitol'' to becoming the center of addiction recovery. We are 
glad to share our lessons with our counterparts around the country and 
with our national leaders. With dedicated partners in Congress who are 
using a public health approach to combat opioid addiction, we can fight 
the epidemic together, save lives and reclaim people and their 
families.
 baltimore city health department's ``3-pillars'' of combating opioid 
                               addiction
    1. Prevent deaths from overdose and save lives. I have declared 
opioid overdose a public health emergency and led the charge in one of 
the most aggressive opioid overdose prevention campaigns across the 
country. This involves a ``Standing Order'' approved by the Maryland 
State Legislature so that I can prescribe the effective antidote, 
naloxone, for the city's 620,000 residents. This year, we have trained 
7,000+ people, including police officers. In the first month of 
carrying naloxone, four officers have used naloxone to save the lives 
of our citizens.
    2. Increasing access to on-demand treatment and long-term recovery 
support. Stopping overdose is only the first step in addressing 
addiction. To treat people with substance addiction, we must ensure 
there is adequate access to on-demand treatment. Nationwide, only 11 
percent of patients with addiction get the treatment they need. 
Baltimore City has taken several actions to ensure access to treatment, 
including a 24/7 crisis, information and referral phone line that, in 
its second month, already has nearly 1,000 calls every week for crisis 
services and referral to appointments; $3.6M in fund to build a 
sobering center; hiring of community-based peer recovery specialists; 
and universal screening hospitals for addiction in our hospitals. We 
strive to establish a 24/7 ``Urgent Care'' for addiction and mental 
health disorders and for increased case management and diversion 
programs.
    3. Provide education to reduce stigma and prevent addiction. In 
addition to treating patients, we must also change the dialog around 
substance use disorder. We are leading a citywide effort to educate the 
public and providers on the nature of addiction: that it is a disease, 
recovery is possible, and we all must play a role in preventing 
addiction and saving lives. We have launched two public education 
campaigns``--DontDie.org'' and ``Bmore in Control''. We have brought 
together hospitals and ER leaders and have implemented citywide best 
practices for opioid prescribing.
                   actions for the federal government
    1. Expand funding and availability of on-demand treatment service.
    2. Provide cities and States with opportunity to innovate around 
addiction recovery.
    3. Monitor and regulate the price and availability of naloxone.
    4. Push for national stigma-reduction and opioid awareness 
campaign.
                                 ______
                                 
    Chairman Alexander, Ranking Member Murray and members of the 
committee, thank you for inviting me to testify on the epidemic of 
opioid abuse that is sweeping across our country. Opioid abuse is an 
epidemic and a public health emergency--one that is claiming the lives, 
the livelihoods, and the souls of our citizens.
    As an emergency room (ER) doctor, I have witnessed firsthand the 
effects of substance addiction on individuals and families, including 
treating hundreds of patients who have overdosed on opioids. My 
colleagues and I frequently felt frustrated by the limitations of 
clinical practice; by the time patients made their way to us, we had 
missed significant opportunities to intervene further upstream in that 
individual's life. This experience is what drove me to public health: a 
desire to tackle the epidemic of opioid abuse at a population level, 
and, in doing so, save individual lives while also redefining our 
societal approach to the treatment of addiction. Now, as the Health 
Commissioner of Baltimore City, I work every day with my dedicated 
staff at the Health Department and partners across our city, to prevent 
overdose and stem the tide of addiction.
                    the opioid problem in baltimore
    With approximately 19,000 active heroin users in Baltimore and far 
more who misuse and abuse prescription opioid medications, our city 
cannot be healthy without addressing opioid addiction and overdose. 
Last year in our city, 303 people died from drug and alcohol overdose, 
which is more than the number of people who died from homicide. Drug 
addiction impacts our entire community and ties into nearly every issue 
facing our city including crime, unemployment, poverty, and poor 
health. It claims lives every day and affects those closest to us--our 
neighbors, our friends, and our family.
    To develop our framework to fight addiction and overdose in 
Baltimore, Mayor Stephanie Rawlings-Blake convened the Heroin Treatment 
and Prevention Task Force in October 2014. Understanding that health is 
not just about physical health, but also behavioral health, the Mayor 
made this one of her administration's top priorities. She charged the 
Task Force with developing bold and progressive recommendations that 
could be implemented to turn the tide against addiction in our city. 
These recommendations serve as our roadmap and call to action, led by 
the Baltimore City Health Department, in close collaboration with 
public and private partners across the city, including our major 
partner, Behavioral Health System Baltimore, a nonprofit that is the 
designated behavioral health authority of the city (of which I serve as 
chair of the board).
             baltimore's response to addiction and overdose
    Our work in Baltimore is built on three pillars:

 First, we have to prevent deaths from overdose and save the 
    lives of people suffering from addiction.
 Second, we must increase access to quality and effective on-
    demand treatment and provide long-term recovery support.
 Third, we need to increase addiction education and awareness 
    for the public and for providers, in order to reduce stigma and 
    encourage prevention and treatment.

    Our work in each of these areas is multifaceted because addressing 
a disease like addiction requires a comprehensive approach. We are glad 
to share these pillars with the committee and appreciate the greater 
national public health focus on this issue. The opioid epidemic is 
affecting every part of our country. We are all in this together, and 
Baltimore is happy to share our innovations and lessons learned.
1. Preventing deaths from overdose
    In Baltimore, I have declared opioid overdose a public health 
emergency and led the charge in one of the most aggressive opioid 
overdose prevention campaigns across the country.

    a. The most critical part of the opioid overdose prevention 
campaign is expanding access to naloxone--the lifesaving drug that 
reverses the effect of an opioid drug overdose. Naloxone is safe, 
easily administered, not addictive, and nearly 100 percent effective at 
reversing an overdose. In my clinical practice, I have administered 
naloxone to hundreds of patients and have seen how someone who is 
unresponsive and about to die will be walking and talking within 
seconds. Since 2003, we have been training drug users on using naloxone 
through our Staying Alive Program. Last year, we successfully advocated 
for change in State legislation so that we can train not only 
individuals who use drugs, but also their family and friends, and 
anyone who wishes to learn how to save a life. This is critical because 
someone who is overdosing will be unresponsive and friends and family 
members are most likely to save their life.
    Our naloxone education efforts are extensive. This year, we have 
trained over 7,000 people to use naloxone: in jails, public housing, 
bus shelters, street corners, and markets. We were one of the first 
jurisdictions to require naloxone training as part of court-mandated 
time in Drug Treatment Court. We have trained State and city 
legislators so that they can not only save lives, but also serve as 
ambassadors and champions to their constituents. We use up-to-date 
epidemiological data to target our training to ``hotspots'', taking 
naloxone directly into the most at-risk communities and putting it in 
the hands of those most in need. This was put into effect earlier this 
year, when we saw that 39 people died from overdose of the opioid 
Fentanyl between January and March of 2015. Fentanyl is many times 
stronger than heroin, and individuals using heroin were not aware that 
the heroin had been laced with Fentanyl. This data led us to target our 
messaging so that we could save the lives of those who were at 
immediate risk.
    Already, our naloxone outreach and trainings are changing the way 
our frontline officials approach addiction treatment, with a focus on 
assessment and action. In addition to training paramedics, we have also 
started to train police officers. The initial trainings were met with 
resistance from the officers who were hesitant to apply medical 
interventions that some did not see as part of their job description. 
However, in the first month of carrying naloxone, four police officers 
used naloxone to save the lives of four citizens. Recently, I attended 
a training where I asked the officers what they would look for if they 
were called to the scene for an overdose. In the past, I would have 
received answers about looking for drug paraphernalia and other 
evidence. This time, officers answered that their job was to find out 
what drugs the person might have taken, to call 911 and administer 
naloxone, because their duty is to save a life. By no means is naloxone 
training the panacea for repairing police and community relations. 
However, it is one step in the right direction as we make clear that 
addiction is a disease and overdose can be deadly. We are changing the 
conversation so that all of our partners can join in encouraging 
prevention, education, and treatment.
    b. As of October 1, 2015, I have the authority to write blanket 
prescriptions for naloxone for the roughly 620,000 residents in 
Baltimore City, under a ``Standing Order'' which was approved by the 
Maryland State Legislature. This is one of the single largest efforts 
in the country to achieve citywide naloxone distribution. A Standing 
Order means that someone can receive a short training (which can be 
done in less than 5 minutes) and immediately receive a prescription for 
naloxone, in my name, without having seen me personally as their 
doctor. We also successfully advocated for Good Samaritan legislation, 
which expanded protections for those who assist in the event of an 
overdose, and malpractice protection for doctors who prescribe 
naloxone. Finally, our State Medicaid program has agreed to set the co-
pay for naloxone at $1. While we still struggle with the pricing for 
naloxone, this has allowed us to provide prescriptions to patients and 
others at a greatly reduced cost. We have to get naloxone into the 
hands of everyone who can save a life--which we believe is each and 
every one of us.
    Some people have the misconception that providing naloxone will 
only encourage a drug user by providing a safety net. This dangerous 
myth is not based on science but on stigma. Would we ever say to 
someone whose throat is closing from an allergic reaction, that they 
shouldn't get epinephrine because it might encourage them to eat 
peanuts or shellfish? An Epi-Pen saves lives; so does naloxone, and it 
should be just as readily available. Our mantra is that we must save a 
life today in order for there to be a better tomorrow.
2. Increasing access to on-demand treatment and long-term recovery 
        support
    Stopping overdose is only the first step in addressing addiction. 
To treat people with substance addiction, we must ensure there is 
adequate access to on-demand treatment. Nationwide, only 11 percent of 
patients with addiction get the treatment they need. There is no 
physical ailment for which this would be acceptable--imagine if only 11 
percent of cancer patients or 11 percent of patients with diabetes were 
being treated. If we do not increase access to quality treatment 
options we are merely treading water, waiting for the person who has 
overdosed to use drugs and overdose again.

    a. In Baltimore, we have started a 24/7 ``crisis, information, and 
referral'' phone line that connects people in need to a variety of 
services including: immediate consultation with a social worker or 
addiction counselor; connection with outreach workers who provide 
emergency services and will visit people in crisis at homes; 
information about any question relating to mental health and substance 
addiction; and scheduling of treatment services and information. This 
line is not just for addiction but for mental health issues, since 
these issues in behavioral health are so closely related and there is a 
high degree of co-occurrence. Those who are seeking treatment for 
behavioral health should be able to easily access the services they 
need, at any time of day. This 24/7 line has been operational since 
October 2015; already, there are nearly 1,000 phone calls every week. 
It is being used not only by individuals seeking assistance, but by 
family members seeking resources and providers looking to connect their 
patients to treatment.
    b. We have secured $3.6 million in capital funds to build a 
``stabilization center''--also known as a sobering center--for those in 
need of temporary service related to intoxication. This is the first 
step in our efforts to start a 24/7 ``Urgent Care'' for addiction and 
mental health disorders--a comprehensive, community-based ``ER'' 
dedicated to patients presenting with substance abuse and mental health 
complaints. Just as a patient with a physical complaint can go into an 
ER any time of the day for treatment, a person suffering from addiction 
must be able to seek treatment on-demand. This center will enable 
patients to self-refer or be brought by families, police, or EMS--a 
``no wrong door'' policy ensures that nobody would be turned away. The 
center would provide full capacity treatment in both intensive 
inpatient and low-intensity outpatient settings, and connect patients 
to case management and other necessary services such as housing and job 
training.
    c. We are developing a real-time treatment dashboard to obtain data 
on the number of people with substance use disorders, near-fatal and 
fatal overdoses, and capacity for treatment. This will enable us to map 
the availability of our inpatient and outpatient treatment slots and 
ensure that treatment availability meets the demand. The dashboard will 
be connected to our 24/7 line that will immediately connect people to 
the level of treatment that they require--on demand, at the time that 
they need it.
    d. We are expanding our capacity to treat overdose in the community 
by hiring community-based peer recovery specialists. These individuals 
will be recruited from the same neighborhoods as individuals with 
addiction, and will be trained as overdose interrupters who can 
administer overdose treatment and connect patients to treatment and 
other necessary services.
    e. We have implemented the Screening, Brief Intervention, and 
Referral to Treatment (SBIRT) approach, which provides universal 
screening of patients presenting to ERs and primary care offices. Three 
of our hospitals are early pioneers in SBIRT; we are looking to expand 
it to all hospitals and clinics in the city to ensure delivery of early 
intervention and treatment services for those with or at risk for 
substance use disorders.
    f. We are expanding and promoting medication-assisted treatment, 
which is an evidence-based and highly effective method to help people 
with opioid addiction recover. This combines behavioral therapy with 
medication, such as methadone or buprenorphine, along with other 
support. Taking medication for opioid addiction is like taking 
medication to control heart disease or diabetes. When prescribed 
properly, medication does not create a new addiction, but rather 
manages a patient's addiction so that they can successfully achieve 
recovery. Baltimore has been at the leading edge of innovation for 
incorporating medication-assisted treatment, including: providing 
medications in structured clinical settings through the Baltimore 
Buprenorphine Initiative. This year, we expanded access to 
buprenorphine treatment by offering services in low-barrier settings, 
such as recovery centers, emergency shelters, and mental health 
facilities. Providing access to buprenorphine services in these 
settings allows us to engage people who are more transient or unstably 
housed into much-needed treatment.
    g. We are working to expand case management and diversion programs 
across the city so that those who need help get the medical treatment 
they need. In our city of 620,000, 73,000 people are arrested each 
year. The majority of these arrests are due to drug offenses. Of the 
individuals in our jails and prisons, 8 out of 10 use illegal 
substances and 4 out of 10 have a diagnosed mental illness. Addiction 
and mental illness are diseases, and we should be providing medical 
treatment rather than incarcerating those who have an affliction. 
Baltimore already has highly effective diversion efforts such as Drug 
Treatment Courts and Mental Health Treatment Courts. We are looking to 
implement a Law Enforcement Assisted Diversion Program, a pilot model 
that has been adopted by a select group of cities, which establishes 
criteria for police officers to identify eligible users and take them 
to an intake facility that connects them to necessary services such as 
drug treatment, peer supports, and housing--rather than to central 
booking for arrest.
    Finally, we are increasing our capability for case management 
services for every individual leaving jails and prisons. These 
individuals are at a highly vulnerable State, and must be connected to 
medical treatment, psychiatric and substance abuse treatments if 
appropriate, housing and employment support, and more. Our outreach 
workers already target a subset of this population; we need to expand 
capacity to every one of these individuals. Additionally, as mentioned 
above, we are deploying community health workers in order to reach 
people where they are in the community as well as provide a credible 
messenger. In deploying this tactic, we are also excited to bring jobs 
and opportunities to vulnerable individuals and neighborhoods that 
otherwise have limited employment opportunities.
3. Providing education to reduce stigma and prevent addiction
    In addition to treating patients, we must also change the dialog 
around substance use disorder. The Baltimore City Health Department is 
leading a citywide effort to educate the public and providers on the 
nature of substance addiction: that it is a disease, recovery is 
possible, and we all must play a role in preventing addiction and 
saving lives.
    a. We have been at the forefront of changing public perception of 
addiction so those in need are not ashamed to seek treatment. We have 
launched a public education campaign ``DontDie.org'' to educate 
citizens that addiction is a chronic disease and to encourage 
individuals to seek treatment. This was launched with bus ads, 
billboard ads, a new website, and a targeted door-to-door outreach 
campaign in churches and with our neighborhood leaders.
    We have also launched a concerted effort to target prevention among 
our teens and youth entitled ``BMore in Control.'' We have established 
permanent prescription drug drop boxes at all nine of the city's police 
stations. This means that anyone can drop-off their unused, unwanted, 
or unnecessary prescription drugs--no questions asked. Drugs left in 
the home can end up in the wrong hands--spouses, elderly family 
members, or even our children. I have treated 2-year-olds who were 
dying from opioid overdose, again underscoring that all of us can be at 
risk and must play a role.
    b. We are targeting our educational efforts to physicians and other 
prescribers of opioid medications. Nationwide, over-prescribing and 
inconsistent monitoring of opioid pain medications is a major 
contributing factor to the overdose epidemic. According to the Centers 
for Disease Control, there were 259 million prescriptions written for 
opioids in 2014. That is enough for one opioid prescription for every 
adult American. Every day, people overdose or become addicted to their 
prescription opioids.
    To address this, I have sent ``best practice'' letters to every 
doctor in the city and will also do so for all dentists and 
pharmacists. The letter addressed the importance of the Prescription 
Drug Monitoring Program and judicious prescribing of opioids, including 
not using narcotics as the first line medication for acute pain and 
emphasizing the risk of addiction and overdose with opioids. 
Importantly, this best practice requires co-prescribing of naloxone for 
any individual taking opioids or at risk for opioid overdose. Hospitals 
keep naloxone on hand if patients receive too much intravenous morphine 
or fentanyl. Patients must also receive a prescription for naloxone if 
they are to be discharged with opioid medications that can result in 
overdose.
    These best practices were developed through convening ER doctors, 
hospital CEOs, and other medical professionals in the city. To reach 
practicing doctors, we have been presenting at Grand Rounds, medical 
society conferences, and are also about to launch physician 
``detailing'', where we will employ teams of public health outreach 
workers and people in recovery to visit doctors to talk about best 
practices for opioid prescribing. We are working with providers to 
ensure best practices will be used when prescribing opioids and that we 
all play our part--as providers, patients, and family members--to 
prevent addiction and overdose.
                  working with the federal government
    The Baltimore City Health Department, together with our partners 
across the city and State, has made significant progress in tackling 
the opioid epidemic. However, there are some areas where we face 
continued challenges. Though there is much that can be done on the city 
and State levels, the Federal Government plays a critical role in the 
campaign against addiction and overdose. We appreciate the opportunity 
to mention four specific areas that can be addressed.
1. Expand funding and availability of on-demand addiction treatment 
        service
    We must treat addiction as a disease and not a crime or a moral 
failing. In order to successfully treat the disease, we need to ensure 
there are sufficient high-quality treatment options available to those 
in need.

    a. Federal funding could expand treatment on-demand including 24/7 
dedicated centers for substance addiction and mental health and proven 
intervention models such as LEAD and expand case management services 
for vulnerable individuals. These programs will help to ensure that 
those in need have a path to recovery.
    b. Congress can push for equitable insurance coverage for addiction 
services. Medicare pays for pain medications that can lead to 
addiction, yet many States do not cover medication-assisted treatment 
and other evidence-based interventions for addiction recovery. Congress 
can ensure that Medicaid, Medicare, and private payers cover on-demand 
treatment for acute care (such as sobering, urgent care, and 
residential services), as well as ongoing treatment and services like 
medication-assisted treatment and case management. These rates should 
also be equivalent to mental health and physical health care rates 
(which they are not currently, leading to a dearth of providers and 
inadequate care).
    c. Congress can remove barriers to prescribing Buprenorphine. 
Buprenorphine is a medication-assisted treatment option with a much 
lower chance of overdose than methadone. Importantly, it can be 
administered by a primary care provider rather than in a designated 
drug-treatment clinic. This helps to increase the accurate perception 
that substance use disorder is a medical condition. Unfortunately, at 
the moment, only medical doctors can prescribe buprenorphine, and a 
doctor can only provide Buprenorphine to a maximum of 100 patients. 
This barrier does not exist for any other medication, and significantly 
limits the ability of patients to access a life-saving treatment option 
and leaves many patients with methadone as their only option for 
medication-assisted treatment. Methadone requires administration in a 
designated treatment clinic, which are often a point of contention 
within the communities in which they operate due to the stigma 
associated with drug addiction. We strongly support current efforts 
underway at the Department of Health and Human Services to revise the 
limits on buprenorphine prescription in a given year, and urge further 
support of broadened access to this proven treatment including by 
requesting Congress to consider broadening prescription authority of 
Buprenorphine to Nurse Practitioners and other providers.
2. Provide Cities and States with the opportunity to innovate around 
        addiction recovery
    There are many services not covered by Medicaid, Medicare, or other 
forms of insurance that are critical to addiction recovery. Congress 
can provide funding to local jurisdictions and to States that can give 
grants and incentives to support innovative, evidence-based programs 
that do not simply focus on the medical component of addiction but the 
broader psychosocial components. These include:

    a. New care delivery models. There is research on new treatment 
options such as starting buprenorphine from ERs, mobile buprenorphine 
induction, or telemedicine treatment that would be not eligible for 
existing reimbursement yet offer much promise. These are examples of 
delivery models that local and State agencies should have the option of 
providing grant funding for, with the option of being included in 
Medicaid formulary after sufficient time and evidence.
    b. Peer recovery specialists. In Baltimore, we are aiming to 
provide a peer recovery specialist for every individual who presents 
for overdose or addiction-related condition to our ERs and other 
facilities. However, we are limited by the lack of funding for these 
individuals. There should be opportunities for expanded funding and 
reimbursement for services rendered by these trained community health 
workers; grant funding to local and State agencies can be one way to 
pursue this.
    c. Case management services. Individuals leaving incarceration or 
inpatient stays are at very high risk; they must receive wrap-around 
services that connect them immediately to needed medical and 
psychiatric assistance. These case management services have 
inconsistent reimbursement; innovative programs including with 
telemedicine and use of peer recovery specialists should be encouraged.
    d. Community resources for recovery. Recovery from addiction 
involves more than clinical treatment but also support and long-term 
care. Local and State agencies can also innovate with interventions 
such as recovery housing and reentry support; Federal funding can 
assist in these necessary steps.
    e. Prevention. Grant support for tailored and targeted prevention 
support including public education and provider education must also be 
a critical component.
3. Congress can monitor and regulate the price and availability of 
        naloxone
    Naloxone is a generic medication that is part of the World Health 
Organization's list of essential medications. Over the last 2 years, 
the price of naloxone has dramatically increased. In Baltimore, the 
cost per dose of naloxone has quadrupled--meaning that we can only save 
a quarter of the lives we could have saved. This is particularly 
problematic for cities and counties that must purchase naloxone for use 
by paramedics, police officers, and other front-line workers. 
Manufacturers have claimed that this price increase is related to 
increased demand. However, it is unclear why the cost of a generic 
medication that is available for much lower costs in other countries 
will be suddenly so expensive. Congress can join efforts by Senator 
Sanders and Congressman Cummings to call for investigation into the 
reason for the price increase, which would otherwise prohibit us from 
saving lives at a time that we need to the most.
4. Congress can push for national stigma-reduction and opioid-awareness 
        campaign
    Many local jurisdictions like Baltimore have launched public 
education campaigns. There is much more education that must be done in 
order to encourage people with addiction into care and to disband 
stigmas that are leading many communities to avoid providing treatment 
altogether. Local jurisdictions are also limited by funding 
constraints. Congress can push for the launch of a national campaign to 
reduce stigma and to increase awareness of opioid addiction. This 
national campaign will provide the spotlight this critical issue 
requires.
                               conclusion
    While some of the challenges facing Baltimore may be unique, we 
join our counterparts around the country in addressing the epidemic of 
opioid addiction. According to the Centers for Disease Control, the 
number of people dying from overdose has quadrupled from 15 years ago. 
In many States, there are more people dying from overdose than from car 
accidents or suicide. Contrary to popular perception, the fastest 
growing demographic of people dying from prescription opioid overdose 
is white and middle-aged women.
    There are some who say the opioid problem is too big and too 
complicated--that it cannot be solved. It is true that treating the 
opioid epidemic requires many approaches. However, this is an issue 
that requires our attention. According to the World Health 
Organization, treating opioid addiction saves society $12 for every $1 
spent on treatment. Treatment also has impact in many other ways to 
communities by reducing excess healthcare utilization, increasing 
productivity and employment rates, and decreasing poverty and 
unnecessary cost to the criminal justice system. Not to mention that it 
is a moral imperative and a matter of life and death.
    Baltimore has been fighting the heroin and opioid epidemic for 
decades and we continue to make progress with bold ideas and innovative 
strategies. Our efforts around opioid addiction seek to change the face 
of Baltimore from the ``heroin capitol'' to becoming the center of 
addiction recovery. We are glad to share our lessons with our 
counterparts around the country and with our national leaders. With 
dedicated partners like you in Congress, we can fight the epidemic 
together, save lives and reclaim people and their families.
    On behalf of the Baltimore City administration, I want to thank you 
for calling this important hearing. We look forward to working with you 
to stop the epidemic of opioid addiction in the United States.

    The Chairman. Thank you, Dr. Wen.
    Dr. Valuck.

   STATEMENT OF ROBERT VALUCK, Ph.D., RPh, FNAP, PROFESSOR, 
DEPARTMENT OF CLINICAL PHARMACY, SKAGGS SCHOOL OF PHARMACY AND 
   PHARMACEUTICAL SCIENCE, UNIVERSITY OF COLORADO, AURORA, CO

    Mr. Valuck. Thank you very much, Chairman Alexander, 
Ranking Member Murray, and members of the committee, for the 
opportunity to provide testimony to you today about our efforts 
to address the opioid epidemic in Colorado.
    In 2012, we had the troubling distinction of ranking 
second, nationally, for self-reported, nonmedical use of 
prescription opioid painkillers. More than 255,000 Coloradans 
misused these drugs, and consequent deaths related to misuse 
nearly quadrupled in our State between 2000 and 2011. As the 
committee is well aware, these dramatic increases in the misuse 
and abuse of prescription drugs have been felt nationwide.
    Since 2012, catalyzed by Governor Hickenlooper's leadership 
as co-chair of the National Governors Association Policy 
Academy for Reducing Prescription Drug Abuse, we are currently 
implementing a unique, innovative, and coordinated approach to 
confront this public health crisis. Drawing upon stakeholder 
input, national best practices, and the success stories from 
other States, we have engaged and leveraged expertise of the 
healthcare community, educators, State and local law 
enforcement, public health, human services, community groups, 
and our legislative partners. In 2012, we set a goal of 
preventing 92,000 Coloradans from engaging in nonmedical use of 
prescription painkillers by 2016 through the adoption of what 
we call the Colorado Plan to Reduce Prescription Drug Abuse.
    The Colorado Plan currently focuses on eight key areas: 
improving surveillance of prescription drug abuse and misuse 
through better data systems; strengthening the Colorado 
Prescription Drug Monitoring Program; educating prescribers and 
other healthcare providers; increasing safe disposal options to 
prevent diversion and protect the environment; increasing 
public awareness; enhancing access and referral to evidence-
based effective treatment; expanding access to the overdose 
reversal drug, naloxone; and, most recently, increasing the 
voice of those who are affected by the epidemic.
    To implement the Colorado Plan and monitor and coordinate 
progress, State level leadership created the Colorado 
Consortium for Prescription Drug Abuse Prevention. The 
Consortium provides a statewide interagency framework designed 
to facilitate collaboration and implementation of the strategic 
plan by interested parties and agencies. The Consortium is 
comprised of eight work groups, separated by the focus areas I 
just outlined, and now it has over 355 members actively 
participating in the effort statewide.
    The Consortium is housed at the university, but draws on 
all of the universities and State agencies that we have in 
Colorado, in addition to all of our health profession 
associations, treatment providers, and other groups. The 
Consortium is a 501(c)(3) organization. It's not housed in any 
one State agency, but includes them all, and provides an 
independent statewide network designed not only to implement 
the strategic plan, but to survive beyond its short-time window 
to continue to address the epidemic over the long period of 
time that will be required to solve it.
    Utilizing this innovative approach, Colorado has 
experienced a wide variety of successes and positive 
developments in each of its areas of focus. I detail those in 
my more substantial testimony, but they come in the form of 
legislation, collaboration, increased public awareness, 
community and affected family engagement, and the new creation 
of a statewide safe disposal program with permanent drop boxes 
in each of Colorado's counties.
    With the Washington Agency Medical Directors' Group 
guidelines serving as a template for us, we developed joint 
prescribing guidelines through our medical, pharmacy, nursing, 
and dental boards to jointly develop a policy for prescribing 
and dispensing opioids in Colorado. We believe, to our 
knowledge, that's the only example of all of the regulatory 
boards in a single State gathering together to create a single 
joint policy.
    We also have received strong bipartisan support from State 
agencies and offices. Our former attorney general, John 
Suthers, contributed a million dollars to the creation of a 
Take Meds Seriously public awareness campaign that we launched 
last spring. Most recently, we have increased access to 
naloxone through the cooperation of major pharmacies and 
pharmacy chains in Colorado, including the Kroger Corporation, 
Safeway-Albertsons, CVS, and a number of other independent 
pharmacies, such that by the first of next year, over 400 
pharmacies in Colorado will have naloxone available through a 
similar standing order issued by our chief medical officer at 
the State level, Dr. Larry Wolk.
    Finally, the Consortium has begun to be recognized as a 
national model for developing State-level approaches to 
addressing this problem. But despite some of the encouraging 
trends, we believe there are several ways that the Federal 
Government could help in the efforts for States to solve the 
opioid epidemic.
    First, we believe Federal funding and agency support could 
be directed to the creation and support of additional State and 
regional level collaboratives to enable sharing of best 
practices and continued dialog among States and regions.
    Second, we believe that the DEA National Take Back 
initiative, while extremely successful in each of its 11 
iterations thus far, could be strengthened to better facilitate 
ongoing permanent mechanisms for drug collection and disposal.
    Third, we have seen and applaud many of the efforts of 
Federal Government agencies and professional organizations to 
create continuing education programs and guidelines for safe 
and effective prescribing, dispensing, and use. We believe that 
what is needed now are tools for providers to enable them to 
implement these educational materials.
    The Chairman. Could you wrap up your testimony, Mr. Valuck? 
Thank you.
    Mr. Valuck. Thank you again for the opportunity to provide 
testimony to the committee today. We would be happy to answer 
any questions you may have related to the work we're doing in 
Colorado to prevent this problem.
    Thank you.
    [The prepared statement of Dr. Valuck follows:]
        Prepared Statement of Robert J. Valuck, Ph.D., RPh, FNAP
                                summary
    Thank you Chairman Alexander, Ranking Member Murray, and members of 
the committee for the opportunity to provide testimony to you today 
about our efforts to address the opioid epidemic in Colorado. In 2012 
(based on 2010-11 data), we had the troubling distinction of ranking 2d 
nationally for self-reported, non-medical use of prescription drugs: 
more than 255,000 Coloradans misused prescription medications, and 
consequent deaths related to misuse nearly quadrupled between 2000 and 
2011. As the committee is well aware, these dramatic increases in the 
misuse and abuse of prescription drugs have been felt nationwide. The 
expenses associated with prescription drug misuse are significant, and 
include costs attributed to lost productivity, criminal justice 
proceedings, treatment, and medical complications.
    Since 2012, catalyzed by Governor Hickenlooper's leadership as a 
co-chair of the National Governor's Association Policy Academy for 
Reducing Prescription Drug Abuse, we are currently implementing a 
unique, innovative, and coordinated approach to confront this public 
health crisis. Drawing upon stakeholder input, national best practices 
and the success stories from other States, we have engaged and 
leveraged expertise of the healthcare community, educators, State and 
local law enforcement, public health, human services, community groups, 
and our legislative partners. In 2012, we set a goal of preventing 
92,000 Coloradans from engaging in non-medical use of prescription pain 
medications by 2016 through the adoption of the Colorado Plan to Reduce 
Prescription Drug Abuse. This commitment represents reduction from 6 
percent to 3.5 percent of Coloradans who self-report non-medical use of 
prescription drugs. Our plan is a coordinated, statewide strategy that 
simultaneously restricts access to prescription drugs for illicit use, 
while ensuring access for those who legitimately need them.
    The Colorado Plan to Reduce Prescription Drug Abuse currently 
focuses on eight key areas:

     improving surveillance of prescription drug misuse data;
     strengthening the Colorado Prescription Drug Monitoring Program;
     educating prescribers and providers;
     increasing safe disposal to prevent diversion and protect the 
environment;
     increasing public awareness;
     enhancing access and referral to evidence-based, effective 
treatment;
     expanding access to the overdose reversal drug Naloxone; and
     increasing the voice of those who are affected by the epidemic.

    To implement the Colorado Plan and monitor and coordinate progress, 
State level leadership created the Colorado Consortium for Prescription 
Drug Abuse Prevention (the Consortium). The Consortium provides a 
statewide, inter-agency/inter-organization framework designed to 
facilitate collaboration and implementation of the strategic plan by 
interested parties and agencies, and is comprised of eight work groups, 
separated by the focus areas outlined above. The Consortium is housed 
at the University of Colorado (CU) Skaggs School of Pharmacy and 
Pharmaceutical Sciences at Anschutz Medical Campus (which houses the 
School of Pharmacy, the Colorado School of Public Health, Colorado 
State University, the University of Northern Colorado, the CU School of 
Medicine, and the CU College of Nursing). The Consortium, a 501c3 
organization that is not housed in any one State agency but includes 
them all, provides an independent statewide network designed not only 
to implement the strategic plan, but to survive beyond its short time 
window to continue to address this epidemic over the long period of 
time that will be required to solve it. The education, governmental, 
and medical communities are well-positioned to address many of 
Colorado's prescription drug abuse challenges, and the partnerships 
facilitated by the Consortium have been crucial in attaining optimum 
outcomes and increased Federal funding.
    Utilizing this innovative, coordinated, multidisciplinary approach, 
Colorado has experienced a wide variety of successes and positive 
developments in each of its areas of focus. These successes have come 
in the form of legislation, collaboration, increased public awareness, 
community and affected family engagement, the creation of a statewide 
safe disposal program, and unprecedented interagency and professional 
association cooperation. Colorado's efforts have received strong 
bipartisan support from various key agencies, offices, and related task 
forces in the State. Our former Attorney General, Jon Suthers, 
contributed $1 million to the work of the Consortium, primarily to 
launch the TakeMedsSeriously public awareness campaign. The Consortium 
has been named an official subcommittee of the legislatively mandated 
Substance Abuse Trend and Response Task Force, which addresses 
substance abuse more broadly, but now benefits from the collective 
expertise of the Consortium.
    Further innovations in Colorado include our Department of Human 
Services, Office of Behavioral Health, including the Consortium in its 
next 5-year Substance Abuse Block Grant funding cycle, to serve as a 
coordinating hub for statewide prevention efforts aimed primarily at 
youth and young adults. Rise Above Colorado, the recipient of the 
statewide prevention grant for 2015-2020, is working to help extend the 
reach of the Consortium, the key messages it has developed, and bring 
them to these key target populations, where the problem of prescription 
drug misuse and abuse most often starts.
    Finally, the Consortium has begun to be recognized as a national 
model for developing a State level, collaborative, coordinated, 
collective action approach to addressing this serious public health 
problem. Through the creation of a common agenda, shared measurement, 
mutually reinforcing activities, continuous communication, and a novel 
backbone infrastructure, we have worked to create a lean but effective 
vehicle for a collective approach to addressing prescription drug abuse 
in Colorado.
    But despite encouraging trends, more needs to be done, and we 
continue to study the problem, engage and listen to all constituents to 
gather their ideas and input, scan the Nation for best practices, 
policies, and programs, and incorporate them into our own efforts. 
While we have made significant progress in Colorado, there is a clear 
place for Federal assistance in fighting this troubling epidemic. The 
current work by all Federal agencies and offices, from HHS (SAMHSA, 
CDC, FDA, HRSA, CMS), to DOJ, DEA, ONDCP, and OIT, among others has 
represented a very good start from a variety of perspectives, but we 
believe there are three specific ways in which you could help States 
address the opioid epidemic.
    First, Federal funding and agency support should be directed to the 
creation and support of State and regional level collaboratives, 
similar to the Consortium model we have created in Colorado, but with 
room for tailoring to the needs of individual States and regions of the 
country. We know that working together is challenging but possible, and 
that each State and region has its own unique needs. Federal support 
could go a long way to creating viable, effective models to attack this 
problem at the appropriate levels, using local expertise and resources, 
where we believe the most success will obtain.
    Second, we believe that the DEA National Takeback Initiative, while 
extremely successful in each of its 11 iterations over the past 6 
years, should be strengthened to better facilitate prescription drug 
take back and destruction. The new regulations allowing pharmacies, 
clinics, and other organizations to become ``reverse distributors'' are 
laudable but we are concerned that sufficient economic incentives for 
these organizations to get into the reverse distribution business are 
lacking. Further, we suggest that the Federal Government assist in the 
creation of a national, permanent takeback network, whereby citizens 
may drop off their unused medications at any time, 365 days a year, and 
thus stem the tide of misuse where it starts, in the medicine cabinet.
    Third, we have seen and applaud the many efforts of government 
agencies and professional organizations to create continuing education 
programs for prescribers and other providers, and to create best 
practice guidelines for safe and effective opioid prescribing, 
dispensing, and use. What is needed now are tools for providers, to 
enable them to implement the educational content and best practices 
into their routine, daily work. Information technology, software 
systems, connectivity, and mobile apps offer clinicians and patients 
the opportunity to make prescribing, dispensing, and using opioids 
safer, more effective, and with the ability to track outcomes and learn 
what works best and what doesn't. Funding for the development, testing, 
and implementation of clinical tools will help us move from ``knowing 
what to do'' to ``knowing how to do it.''
    With additional help in these three areas, States will have 
substantially more resources, brainpower, and tools to address the 
opioid epidemic in their States and regions. We hope you will consider 
these suggestions, and work to develop policies and programs to support 
them.
    In closing, while there is still much work to do in response to 
this public health crisis, we are emboldened by some of the progress 
seen in Colorado. We have confidence that the Consortium model will 
allow us to implement a multi-faceted, strategic approach that is 
responsive to changing trends and data, and the continued development 
of national best-practice. The Colorado Plan to Reduce Prescription 
Drug Abuse is a crucial part of our commitment to making Colorado the 
healthiest State in the Nation. Better health is not just good for 
individuals and families; it has positive outcomes for our workforce, 
reduces the costs of government, and improves the quality of life in 
our communities.
    Thank you, again, for the opportunity to provide testimony today. 
We would be happy to answer any questions related to the work we are 
doing in Colorado to prevent the misuse and abuse of prescription 
drugs.
                                 ______
                                 
    Thank you Chairman Alexander, Ranking Member Murray, and members of 
the committee for the opportunity to provide testimony to you today 
about our efforts to address the opioid epidemic in Colorado. In 2012 
(based on 2010-11 data), we had the troubling distinction of ranking 2d 
nationally for self-reported, non-medical use of prescription drugs: 
more than 255,000 Coloradans misused prescription medications, and 
consequent deaths related to misuse nearly quadrupled between 2000 and 
2011. As the committee is well aware, these dramatic increases in the 
misuse and abuse of prescription drugs have been felt nationwide. The 
expenses associated with prescription drug misuse are significant, and 
include costs attributed to lost productivity, criminal justice 
proceedings, treatment, and medical complications.
    Since 2012, catalyzed by Governor Hickenlooper's leadership as a 
co-chair of the National Governor's Association Policy Academy for 
Reducing Prescription Drug Abuse, we are currently implementing a 
unique, innovative, and coordinated approach to confront this public 
health crisis. Drawing upon stakeholder input, national best practices 
and the success stories from other States, we have engaged and 
leveraged expertise of the healthcare community, educators, State and 
local law enforcement, public health, human services, community groups, 
and our legislative partners. In 2012, we set a goal of preventing 
92,000 Coloradans from engaging in non-medical use of prescription pain 
medications by 2016 through the adoption of the Colorado Plan to Reduce 
Prescription Drug Abuse. This commitment represents reduction from 6 
percent to 3.5 percent of Coloradans who self-report non-medical use of 
prescription drugs. Our plan is a coordinated, statewide strategy that 
simultaneously restricts access to prescription drugs for illicit use, 
while ensuring access for those who legitimately need them.
    The Colorado Plan to Reduce Prescription Drug Abuse currently 
focuses on eight key areas:

     improving surveillance of prescription drug misuse data;
     strengthening the Colorado Prescription Drug Monitoring Program;
     educating prescribers and providers;
     increasing safe disposal to prevent diversion and protect the 
environment;
     increasing public awareness;
     enhancing access and referral to evidence-based, effective 
treatment;
     expanding access to the overdose reversal drug Naloxone; and
     increasing the voice of those who are affected by the epidemic.

    To implement the Colorado Plan and monitor and coordinate progress, 
State level leadership created the Colorado Consortium for Prescription 
Drug Abuse Prevention (the Consortium). The Consortium provides a 
statewide, inter-agency/inter-organization framework designed to 
facilitate collaboration and implementation of the strategic plan by 
interested parties and agencies, and is comprised of eight work groups, 
separated by the focus areas outlined above. The Consortium is housed 
at the University of Colorado (CU) Skaggs School of Pharmacy and 
Pharmaceutical Sciences at Anschutz Medical Campus (which houses the 
School of Pharmacy, the Colorado School of Public Health, Colorado 
State University, the University of Northern Colorado, the CU School of 
Medicine, and the CU College of Nursing). The Consortium, a 501c3 
organization that is not housed in any one State agency but includes 
them all, provides an independent statewide network designed not only 
to implement the strategic plan, but to survive beyond its short time 
window to continue to address this epidemic over the long period of 
time that will be required to solve it. The education, governmental, 
and medical communities are well-positioned to address many of 
Colorado's prescription drug abuse challenges, and the partnerships 
facilitated by the Consortium have been crucial in attaining optimum 
outcomes and increased Federal funding.
    Utilizing this innovative, coordinated, multidisciplinary approach, 
Colorado has experienced a wide variety of successes and positive 
developments in each of its areas of focus.
    Thorough and accurate data and research underpins the work that we 
do and informs the policy and regulatory decisions that we make. The 
Data and Research work group of the Consortium has worked to map out 
all sources of data related to prescription drug use, misuse and 
overdose in the State in order to monitor trends, educate the public 
and inform decisionmaking by multiple stakeholders. The work group is 
also focused on identifying other efforts that successfully use 
crosswalks between diverse data sources and standardize data collection 
tools across State agencies. Under a new DOJ-BJA Harold Rogers grant, 
our Colorado Department of Public Health is working with the PDMP 
program and the Consortium to create better, more current, and linked 
data systems. This will enable us to better identify high risk 
populations and geographic areas, and to use this ``hot spotting'' 
approach to rapidly respond to any emerging public health concerns if 
or when they arise.
    The Prescription Drug Monitoring work group (PDMP) has worked over 
the past 2 years to enhance our State's PDMP as an effective public 
health tool. In 2014 we passed House Bill 1283, enhancing our State's 
PDMP. This bill included a variety of provisions, most notably: 
allowing the State to provide ``push notices'' to both prescribers and 
pharmacists when patients visit a certain number of prescribers and 
pharmacies to obtain a controlled substance over a certain period of 
time; requiring mandatory PDMP registration for pharmacists and United 
States Drug Enforcement Administration (DEA) registered prescribers; 
allowing prescribers and pharmacists to assign and register delegates 
in their office to check the PDMP; allowing direct access to PDMP by 
the Colorado Department of Public Health and Environment; and providing 
permissive authority for federally owned and operated pharmacies to 
submit controlled substances data into the Colorado PDMP. Additionally, 
we have enhanced the PDMP interface and moved to a daily upload of data 
(it was twice monthly prior to October 2014). These improvements have 
demonstrated a powerful resonance throughout the Colorado prescriber 
and pharmacist community. As of July 2014 our PDMP utilization rate was 
41 percent and by October 2015 that rate had more than doubled, 
reaching 85 percent.
    The Provider Education work group focuses on issues relating to 
improving the education and training of health care professionals who 
prescribe, dispense, or otherwise provide care for those receiving 
prescription medications with the potential for misuse, abuse, or 
diversion. In the spring of 2014, a joint Policy for Prescribing and 
Dispensing Opioids was developed to address prescription drug abuse in 
the State and adopted by the dental, medical, nursing, pharmacy, 
optometry, and podiatry boards in Colorado. This is the first joint 
policy of its type adopted by multiple regulatory boards in a single 
State, and aims to provide guidance on best practices for pain 
management. Over the past year the Consortium has also developed online 
training and education for prescribers throughout the State.
    As of October 2014, 1,316 prescribers had completed the training, 
87 percent of whom indicated they intended to change their practice as 
a result. The Provider and Prescriber Education Workgroup of the 
Consortium is currently expanding the curriculum to other professional 
health schools and postgraduate training programs. We were encouraged 
by these strategies when the CDC morbidity and mortality report 
recently ranked Colorado 40th nationally for prescribing rates of 
opioids per 100,000 people (50th being the lowest rates of 
prescribing).
    We know that more than 70 percent of those who abuse prescription 
drugs obtain them from the unused supplies of friends or family, 
highlighting the importance of supporting robust medication collection 
and disposal resources throughout the State. The Safe Disposal work 
group focuses on issues relating to safe storage and disposal of 
prescription medications with the potential for misuse, abuse or 
diversion. This work group has developed guidelines and outreach 
efforts and expanded the number of safe disposal sites throughout the 
State. For the past 5 years, the DEA has operated ``National Drug 
Takeback Days'' each Spring and Fall, collecting significant quantities 
of medications at law enforcement sites (over 39,000 pounds in Colorado 
in 2014 alone). In light of the uncertainty regarding future DEA 
takeback days, and responding to the new DEA rules allowing ``reverse 
distribution'' of pharmaceutical controlled substances, we secured 
State funding to expand the existing collection and disposal program. 
Over the next year, we plan to provide permanent drop boxes in every 
county to assure an ongoing, available mechanism for all citizens to 
safely dispose of unused/unwanted medications.
    The Public Awareness work group of the Consortium focuses on 
raising awareness among Colorado citizens regarding the problem of 
prescription drug abuse. We recently launched a new statewide 
advertising and public outreach campaign--``Take Meds Seriously''--
designed to educate consumers about the safe use, storage, and disposal 
of prescription drugs. Since our February 2015 launch, our new 
website--TakeMedsSeriously.org--has seen over 53,000 visits and 76,000 
page views in less than 6 months; has had over 76 Million advertising 
impressions and over 62,000 click throughs; has received nearly 
$100,000 in earned media coverage; and has increased awareness of the 
problem, as evidenced by 2 of 10 Coloradans reporting having heard or 
seen a campaign message, and 81 percent of those saying that they would 
talk to their children or family members about the dangers of 
prescription medicine abuse.
    The Consortium's Treatment work group has focused on identifying 
gaps and needs in the provision of preventative, therapeutic, and 
rehabilitative substance use treatment programs and making clinical, 
organization, and public policy improvements to these systems. Primary 
areas of focus are: (1) lack of standardized, universal screening, 
brief intervention, referral, and treatment (or SBIRT); (2) barriers to 
access and entry; and (3) critical treatment and clinical workforce 
shortages. We are working from a variety of vantage points to expand 
access to and availability of treatment resources, such as expanding 
statewide capacity to provide Medication Assisted Treatment (MAT) for 
opiate dependent patients by linking suboxone-licensed physicians with 
community-based substance treatment. We recently applied to the 
Substance Abuse and Mental Health Services Administration (SAMHSA) for 
a Targeted Capacity Expansion grant aimed at increasing the capacity to 
deliver MAT to treat opiate/opioid addiction.
    The Naloxone work group focuses on increasing awareness of, and 
access to, the opioid overdose reversing drug Naloxone, and making 
clinical, organizational, and public policy recommendations to achieve 
this goal. This spring, we passed Senate bill 15-053, which extends 
existing authority to prescribe or dispense opiate antagonists by 
permitting licensed prescribers and licensed dispensers to also 
prescribe or dispense a standing order directly to individuals, a 
friend or family member or an individual who may experience an opiate-
related drug overdose, an employee or volunteer of a harm reduction 
organization or a first responder. Shortly thereafter, our State's 
Chief Public Health Officer, Dr. Larry Wolk, issued a standing order 
for all citizens of Colorado. In recent weeks, the Naloxone work group 
has worked closely with both small, independent pharmacies and major 
supermarket and chain pharmacies, to increase the number of locations 
who are dispensing Naloxone under the new standing orders. We are 
pleased to report that the Kroger Corporation, Safeway/Albertsons, and 
CVS have all signed on, and as of January 2016, Naloxone will be 
available in over 400 pharmacies across the State of Colorado, 
providing widespread distribution of life-saving opiate antagonists.
    The new Affected Families and Friends work group, launched this 
Fall, focuses on giving those affected by the opioid epidemic a place 
to go, a place to learn, a place to share their stories and experiences 
with others, a network for providing media access and interviews, and a 
vehicle to give input to the consortium's topic area work groups and 
the State legislature, regarding what patients and families experience, 
want, and need, as they live their lives under the impact of opioid 
misuse, abuse, and overdose. To our knowledge, no other State is 
currently engaging patients and families in this way, as part of their 
statewide efforts to address the epidemic.
    It is also important to note that Colorado's efforts have received 
strong bipartisan support, from various key agencies, offices, and 
related task forces in the State. Our former Attorney General, Jon 
Suthers, contributed $1 Million to the work of the Consortium, 
primarily to launch the TakeMedsSeriously public awareness campaign. 
And the Consortium has been named an official subcommittee of the 
legislatively mandated Substance Abuse Trend and Response Task Force, 
which addresses substance abuse more broadly, but now benefits from the 
collective expertise of the Consortium.
    Further innovations in Colorado include our Department of Human 
Services, Office of Behavioral Health, including the Consortium in its 
next 5-year Substance Abuse Block Grant funding cycle, to serve as a 
coordinating hub for statewide prevention efforts aimed primarily at 
youth and young adults. Rise Above Colorado, the recipient of the 
statewide prevention grant for 2015-20, is working to help extend the 
reach of the Consortium, the key messages it has developed, and bring 
them to these key target populations, where the problem of prescription 
drug misuse and abuse most often starts.
    Finally, the Consortium has begun to be recognized as a national 
model for developing a State level, collaborative, coordinated, 
collective action approach to addressing this serious public health 
problem. Through the creation of a common agenda, shared measurement, 
mutually reinforcing activities, continuous communication, and a novel 
backbone infrastructure, we have worked to create a lean but effective 
vehicle for a collective approach to addressing prescription drug abuse 
in Colorado. Recent data suggests that we are well on track to meet our 
2016 goal. 2013 data released by the National Survey on Drug Use and 
Health shows that our rate on non-medical use has decreased from 6 
percent to 5.08 percent, which represents 39,000 fewer Coloradans who 
misused prescription drugs during the survey time period (2012-13). 
This drop represents a 15.33 percent reduction in our rate of 
prescription drug abuse, and our ranking in this category has 
positively dropped from 2d to 12th nationally. Additionally, the 
Colorado youth use rate is decreasing and below the national average. 
In 2011, the percentage of students who had taken prescription drugs 
without a doctor's permission more than once during their lifetime was 
19.6 percent. In 2013 that percentage had dropped to 13.6 percent.
    But despite encouraging trends, prescription drug abuse remains a 
serious health crisis as we work to expand upon and bolster work 
currently underway in Colorado. Drug overdose remains the leading cause 
of injury death in the United States and in Colorado, largely due to 
the misuse and abuse of prescription drug overdoses, and 10.72 percent 
Coloradans aged 18-25 still engage in non-medical use of prescription 
drugs. In the last 5 years the number of heroin users in Colorado has 
also doubled, a rate increase that is suspected to have some 
correlation with our high rates of prescription drug misuse/abuse. We 
also have significant concerns that existing treatment capacity is not 
meeting a rising demand, as treatment admissions for heroin and 
prescription opioid abuse increased 128 percent between 2007 and 2014. 
Overdose death is a very real risk for people struggling with opiate 
addiction, and failure to provide vital treatment services means 
unnecessary, preventable deaths of our citizens.
    More needs to be done, and we continue to study the problem, engage 
and listen to all constituents to gather their ideas and input, scan 
the Nation for best practices, policies, and programs, and incorporate 
them into our own efforts. While we have made significant progress in 
Colorado, there is a clear place for Federal assistance in fighting 
this troubling epidemic. The current work by all Federal agencies and 
offices, from HHS (SAMHSA, CDC, FDA, HRSA, CMS), to DOJ, DEA, ONDCP, 
and OIT, among others has represented a very good start from a variety 
of perspectives, but we believe there are three specific ways in which 
you could help States address the opioid epidemic:
    First, Federal funding and agency support should be directed to the 
creation and support of State and regional level collaboratives, 
similar to the Consortium model we have created in Colorado, but with 
room for tailoring to the needs of individual States and regions of the 
country. We know that working together is challenging but possible, and 
that each State and region has its own unique needs. Federal support 
could go a long way to creating viable, effective models to attack this 
problem at the appropriate levels, using local expertise and resources, 
where we believe the most success will obtain.
    Second, we believe that the DEA National Takeback Initiative, while 
extremely successful in each of its 11 iterations over the past 6 
years, should be strengthened to better facilitate prescription drug 
take back and destruction. The new regulations allowing pharmacies, 
clinics, and other organizations to become ``reverse distributors'' are 
laudable but we are concerned that sufficient economic incentives for 
these organizations to get into the reverse distribution business are 
lacking. Further, we suggest that the Federal Government assist in the 
creation of a national, permanent takeback network, whereby citizens 
may drop off their unused medications at any time, 365 days a year, and 
thus stem the tide of misuse where it starts, in the medicine cabinet.
    Third, we have seen and applaud the many efforts of government 
agencies and professional organizations to create continuing education 
programs for prescribers and other providers, and to create best 
practice guidelines for safe and effective opioid prescribing, 
dispensing, and use. What is needed now are tools for providers, to 
enable them to implement the educational content and best practices 
into their routine, daily work. Information technology, software 
systems, connectivity, and mobile apps offer clinicians and patients 
the opportunity to make prescribing, dispensing, and using opioids 
safer, more effective, and with the ability to track outcomes and learn 
what works best and what doesn't. Funding for the development, testing, 
and implementation of clinical tools will help us move from ``knowing 
what to do'' to ``knowing how to do it.''
    With additional help in these three areas, States will have 
substantially more resources, brainpower, and tools to address the 
opioid epidemic in their States and regions. We hope you will consider 
these suggestions, and work to develop policies and programs to support 
them.
    In closing, given some of the highlighted successes we've had and 
challenges we still face, recent data suggests that we are well on 
track to meet our 2016 goal. 2013 data released by the National Survey 
on Drug Use and Health shows that our rate on non-medical use has 
decreased from 6 percent to 5.08 percent, which represents 39,000 fewer 
Coloradans who misused prescription drugs during the survey time period 
(2012-13). This drop represents a 15.33 percent reduction in our rate 
of prescription drug abuse, and our ranking in this category has 
positively dropped from 2d to 12th nationally. Additionally, the 
Colorado youth use rate is decreasing and below the national average. 
In 2011, the percentage of students who had taken prescription drugs 
without a doctor's permission more than once during their lifetime was 
19.6 percent. In 2013 that percentage had dropped to 13.6 percent. The 
national average for this measure in 2013 was 17.8 percent. While there 
is still much work to do in response to this public health crisis, we 
are emboldened by some of the progress seen in Colorado. We have 
confidence that the Consortium model will allow us to implement a 
multi-faceted, strategic approach that is responsive to changing trends 
and data, and the continued development of national best-practice. The 
Colorado Plan to Reduce Prescription Drug Abuse is a crucial part of 
our commitment to making Colorado the healthiest State in the Nation. 
Better health is not just good for individuals and families; it has 
positive outcomes for our workforce, reduces the costs of government, 
and improves the quality of life in our communities.
    Thank you, again, for the opportunity to provide testimony today. 
We would be happy to answer any questions related to the work we are 
doing in Colorado to prevent the misuse and abuse of prescription 
drugs.
                              Attachments
    Note: Due to the high cost of printing, the attachments supplied by 
Mr. Robert Valuck, Ph.D. may be accessed at the following websites:


 Attachment 1--Colorado Plan to Reduce Prescription Drug Abuse 
    at: www.
    cohealthinfo.com/wp-content/uploads/2014/08/Colorado-Plan-to-
    Reduce-Prescription-Drug-Abuse-Sep-2013.pdf.

 Attachment 2--Colorado Consortium for Prescription Drug Abuse 
    Prevention Chart at: www.corxconsortium.org/wp-content/uploads/
    TakeMeds_About_Chart
    -2.png.

 Attachment 3--TakeMedsSeriously Wrap-Up Report at: https://
    coag-gov/sites/default/files/contentuploads/oce/Substance-Abuse_SA/
    SATF_presentations/11-0-15_tmswrap-up-report.pdf.

 Attachment 4--The Colorado Consortium for Prescription Drug 
    Abuse Prevention, Public Awareness Work Group's 2015 Statewide 
    Survey Report of Results at: https://www.corxconsortium.org.

    The Chairman. Thank you very much.
    Mr. Spofford.

 STATEMENT OF ERIC SPOFFORD, CHIEF EXECUTIVE OFFICER, GRANITE 
     HOUSE, DERRY, NH; NEW FREEDOM ACADEMY, CANTERBURY, NH

    Mr. Spofford. Good morning. It's an honor and privilege to 
be here. I'm the chief executive officer of two substance abuse 
treatment programs in New Hampshire and have a third opening up 
early next year. I'm also in long-term recovery from opiate and 
other drug addiction. I've been sober since December 7, 2006. 
I'd like to share some of my personal experience with the 
opiate epidemic.
    In the late 1990s, a drug called Oxycontin was marketed as 
a non-addictive pain killer. This drug was an opiate, the same 
class of drug as heroin, with a similar potency. It had a time 
release coating on it that was easily removed by moistening it 
and rubbing it off, making Oxycontin a highly abusable and 
addictive drug.
    In 1999, I was a teenager and experimenting with drugs and 
alcohol. A friend that I grew up with since first grade came 
over with a 20 milligram pill. We crushed it, snorted it, and 
it was the most euphoric thing I had ever experienced and I 
fell in love instantly. The next day, all I wanted to do was 
more. I had no idea that my life had just changed forever.
    What started as recreational use quickly turned into daily 
use and addiction. My tolerance for the drug became 
increasingly stronger. I dropped out of high school and shortly 
after graduated into using heroin, as most opiate addicts do. 
Before I knew it, it was too late.
    Through 6 years of opiate addiction, I did and experienced 
many things I'm not proud of. I committed crimes to support my 
habit, got in legal trouble, was homeless, overdosed five 
times, and was a general burden on society. I attempted to 
achieve recovery many times before I finally did. On the 
morning of December 7, 9 years ago, I was done for good.
    Since then, I've been in recovery, and I've been able to 
accomplish a lot. I'm a man of integrity today, a good friend, 
son, boyfriend, and father. I'm respected in my community, and 
recently I won the business of the year award from the chamber 
of commerce. At every opportunity possible, I'm of service, 
especially when it comes to combating the heroin epidemic.
    In 2008, I started a program called the Granite House, a 
men's sober living home that quickly grew into a nationally 
recognized extended care program. Recently, I opened another 
residential inpatient facility, with another opening in early 
2016. I also own several other businesses in the construction 
and real estate space. I've created close to 100 jobs in my 
home State of New Hampshire, and I have paid my fair share of 
taxes along the way.
    I tell you all of this because 9 years ago, I was a man 
that appeared hopeless. I was a guy that was hard to like. I 
created a lot of problems everywhere I went because of my 
addiction, and because of the stigma associated with this 
disease, most people had given up on me.
    Supporting addicts in their recovery process can have far 
greater benefit than just to them and their lives. We are some 
of the most intelligent and creative people that I have ever 
met and have the potential to do so much in this world, 
although it often doesn't appear so.
    I have witnessed the opiate epidemic spiral out of control 
for a long time. The solution must be comprehensive with 
prevention and treatment. In the last several years, fentanyl 
has become widely available on the streets. It is a synthetic 
opiate that is 50 times more powerful than heroin and much 
cheaper. The dealers are cutting their heroin with it or 
selling it in the place of heroin for greater profits.
    This has created an inconsistency of potency in the drugs 
that are on the streets and it is killing people. I've buried 
more people of drug overdoses in the last 2 years than I have 
in all the years before combined. On average, in New Hampshire, 
I know of two to four people that die a week.
    Creating harder sentencing laws for the distribution and 
trafficking of fentanyl is incredibly important. This drug is a 
serial killer and so are the people selling it. They see the 
carnage it creates and keep selling it, despite how many people 
are dying.
    Also important is the availability of naloxone, the 
lifesaving overdose reversal drug. The symptoms of the disease 
of addiction are ugly and make addicts hard people to like. The 
question we need to ask ourselves is do they deserve to die 
because of their disease? I overdosed five times and was 
revived with this drug. Without it, I would be dead and my life 
would have never had any meaning.
    We must have better prevention systems in our schools. 
Young people experimenting with drugs is nothing new. What is 
new is that what is available to them is heroin, and it will 
change their lives forever and they don't even know it. We need 
to educate our children on the truth of opiates and the effects 
it will have on them and their peers.
    Treatment availability is incredibly important. If we can 
support addicts from being in active addiction to getting into 
the recovery process, we will start to gain traction on this 
epidemic. Providing treatment for people with this disease is 
far less expensive than incarcerating them and so much more 
effective.
    People do need to be held accountable for their actions. 
However, putting addicts in prison and expecting them to be 
different when they get out is of the same mentality as locking 
up a diabetic and expecting them to not have diabetes when 
released. The disease of addiction does not respond to 
punishment.
    I sincerely appreciate your attention to this matter, and 
thank you for your time.
    [The prepared statement of Mr. Spofford follows:]
                  Prepared Statement of Eric Spofford
                                summary
    I. Opening comments
        A. Introduction
        B. Recovery background

    II. Active addiction
        A. Prescription drug Oxycontin
        B. Point of no return
        C. Addiction behavior
        D. Attempts at recovery, failure

    III. Personal recovery and afterwards
        A. Complete turnaround
        B. Accomplishment
        C. Service

    IV. Recovery professional
        A. The Granite House beginnings
        B. New Freedom Academy
        C. Green Mountain Treatment Center
        D. Entrepreneurship
        E. From hopeless to helpful

    V. The Epidemic
        A. Fentanyl
        B. Stricter laws
        C. Naloxone (Narcan)

    VI. Prevention and treatment
        A. Teach our children
        B. Treatment availability
        C. Treatment and accountability over jail--treat as a disease

    VII. Closing
                                 ______
                                 
    Good morning, my name is Eric Spofford and it is an honor and a 
privilege to be here. I am the chief executive officer of two substance 
abuse treatment programs in New Hampshire and have a third opening up 
early next year.
    I'm also in long-term recovery from opiate and other drug 
addiction. I've been sober since December 7, 2006.
    I'd like to share some of my personal experience with the opiate 
epidemic. In the late 1990s a drug called Oxycontin was marketed as a 
non-addictive pain killer. This drug was an opiate, the same class of 
drug as heroin with a similar potency. It had a time release coating on 
it that was easily removed by moistening it and rubbing it off, making 
Oxycontin a highly abusable and addictive drug.
    In 1999, I was a teenager and experimenting with drugs and alcohol. 
A friend that I grew up with since first grade came over with a 20 
milligram pill. We crushed it up and snorted it. It was the most 
euphoric thing I had ever experienced and I fell in love instantly. The 
next day all I wanted to do was more. I had no idea that my life had 
just changed forever.
    What started as recreational use quickly turned into daily use and 
addiction. My tolerance for the drug became increasingly stronger. I 
dropped out of high school and shortly after graduated into using 
heroin, as most opiate addicts do. Before I knew it, it was too late.
    Through 6 years of opiate addiction I did and experienced many 
things I'm not proud of. I committed crime to support my habit, got in 
legal trouble, was homeless, overdosed five times, and was a burden on 
society.
    I attempted to achieve recovery many times before I finally did. 
But on the morning of December 7, 9 years ago, I was done for good.
    Since then I've been in recovery I've been able to accomplish a 
lot. I'm a man of integrity today, a good friend, son, boyfriend, and 
father. I'm respected in my community and recently I won the business 
of the year award from the chamber of commerce. At every opportunity 
possible I'm of service, especially when it comes to combating the 
heroin epidemic.
    In 2008, I started a program called The Granite House, a men's 
sober living home that quickly grew into a nationally recognized 
extended care program. Recently I opened a residential inpatient 
treatment center called New Freedom Academy and I have another 
inpatient facility called Green Mountain Treatment Center opening in 
early 2016.
    I also own several other businesses in the construction and real 
estate space. I've created close to a hundred jobs in my home State of 
New Hampshire and I have paid my fair share of taxes along the way.
    I tell you all of this because 9 years ago I was a man that 
appeared hopeless. I was a guy that was hard to like, I created a lot 
of problems everywhere I went because of my addiction, and because of 
the stigma associated with this disease most people had given up on me. 
Supporting addicts in their recovery process can have far greater 
benefit than just to them and their lives. We are some of the most 
intelligent and creative people that I have ever met and have the 
potential to do so much in this world, although it often doesn't appear 
so.
    I have witnessed the opiate epidemic spiral out of control for a 
long time. The solution must be comprehensive with prevention and 
treatment.
    In the last several years fentanyl has become widely available on 
the streets. It is a synthetic opiate that is 50 times more powerful 
than heroin and much cheaper. The dealers are cutting their heroin with 
it or selling it in the place of heroin, for greater profits. This has 
created an inconsistency of potency in the drugs that are on the street 
and it is killing people. I've buried more people of drug overdoses in 
the last 2 years than I have in all the years before combined. On 
average I know of two to four people that die a week.
    Creating harder sentencing laws for the distribution and 
trafficking of fentanyl is incredibly important. This drug is a serial 
killer and so are the people selling it. They see the carnage it 
creates and keep selling it despite how many people are dying.
    Also important is the availability of naloxone, the life saving 
overdose reversal drug. The symptoms of the disease of addiction are 
ugly and make addicts hard people to like. But the question we need to 
ask ourselves is, do they deserve to die because of their disease? I 
overdosed five times and was revived with this drug. Without it I would 
be dead and my life would have never had any meaning.
    We must have better prevention systems in our schools. Young people 
experimenting with drugs is nothing new. What is new is that what is 
available to them is heroin and will change their life forever and they 
don't even know it. We need to educate our children on the truth of 
opiates and the effects it will have on them and their peers.
    Treatment availability is incredibly important. If we can support 
addicts from being in active addiction to getting into the recovery 
process we will start to gain traction on this epidemic. Providing 
treatment for people with this disease is far less expensive than 
incarcerating them and so much more effective. People do need to be 
held accountable for their actions. However putting addicts in prison 
and expecting them to be different when they get out is of the same 
mentality as locking up a diabetic and expecting them to not have 
diabetes when released. The disease of addiction does not respond to 
punishment.
    I sincerely appreciate your attention to this matter. Thank you for 
your time.

    The Chairman. Thank you, Mr. Spofford, and thank you for 
your personal story.
    Thanks to all three witnesses. We'll now begin a round of 
5-minute questions each. I'll go first, and then Senator 
Murray.
    Mr. Spofford, Dr. Wen talked about the medicine, naloxone, 
that's used when there's an emergency overdose, it sounds like. 
Take me through the process at the Granite House if, suddenly, 
you're introduced to someone who's in the midst of an overdose. 
Do you administer naloxone, or does someone do that? I believe 
you told me earlier that you gradually help people off their 
addiction within about a week. Is that right?
    Mr. Spofford. Sure. What you're referencing is the detox 
process. Understand that opiates, as a class of drugs, has a 
physical dependency and that folks go into withdrawal in the 
absence of them. A national standard is about a 5- to 7-day 
process of a taper, using a drug such as buprenorphine, to 
bring them back to sobriety.
    Naloxone is not commonly used--it's actually never been 
used at the Granite House, my facility, because people aren't 
on drugs and alcohol there. In fact, they're achieving sobriety 
and are sober at that period of time. More often than not, 
we're seeing first responders administering naloxone. We're 
also seeing it being administered among the addicts.
    The Chairman. Someone may have administered naloxone, and 
then they bring that person to you later. Is that right?
    Mr. Spofford. Correct, to come to treatment.
    The Chairman. Some people say that a drug like methadone is 
needed for a long period of time for someone to get over an 
opiate addiction, and some people--and, obviously, you think 
it--you prescribe a different sort of treatment. Talk about 
that.
    Mr. Spofford. Methadone and buprenorphine, or the brand 
name, Suboxone, same thing, are replacement drugs, whereas they 
themselves are narcotics. If I took one right now, or anyone in 
this room did, you'd be high as a kite. You're still 
maintaining a physical addiction to opiates. It's just taking 
it from heroin and prescription medications bought illegally to 
a prescription under the oversight of a doctor.
    I couldn't imagine what my life would look like if I woke 
up this morning and had to take a pill to not go into 
withdrawal before I came here to share with you. I believe in 
abstinence-based treatment. The treatment industry is very much 
split down the middle and polarized to two different types, 
medication-assisted recovery and abstinence-based. My 
facilities, my own personal program of recovery, and my 
industry peers believe that we can be free from all mind-
altering substances, and we don't need a crutch such as 
buprenorphine or methadone to stay away from heroin.
    The Chairman. Dr. Wen, what's your comment on that? Is it 
necessary to have a medicated recovery from an opiate 
addiction, or is it better not to?
    Dr. Wen. First, I wish to say that Mr. Spofford's testimony 
was extremely touching and inspiring. From my standpoint, I 
have to use evidence and I have to use science, because I'm a 
doctor and a scientist. When we look at dozens, hundreds, of 
studies that have been done, they show that medication-assisted 
treatment works. Let me distinguish between the two, if I may.
    The Chairman. When do you get to the end of medicated-
assisted treatment? How long do you have that? Does that go on 
for the rest of your life?
    Dr. Wen. Many patients are maintained on medications for 
the rest of their life, and I would equate that to high blood 
pressure or diabetes. I would never say to somebody with high 
blood pressure, ``Why is it that you're still taking your 
Lisinopril? It's been 30 years,'' or say to somebody, ``Why are 
you still taking your insulin? You've had diabetes for quite a 
long time.''
    We know that opioid addiction is a chronic disease of the 
brain, very similar to other physical ailments. Studies have 
shown that most individuals would benefit from chronic 
medication-assisted treatments, and that when somebody is 
stably maintained on methadone or buprenorphine, it does not 
cause them to ``have a high,'' that these certainly can be 
misused in the same way that oxycodone or any other opioid 
could be misused, but that somebody could be stably maintained 
on these medications, and that they will look no different from 
you and me, they will not be prohibited from operating 
machinery or driving, and that this is the path to long-term 
recovery that is evidence-based.
    The Chairman. Dr. Valuck, that's a difference of opinion. I 
suppose another difference of opinion, one which you referred 
to, is among physicians and their prescriptions for opiate 
addiction. Dr. Frieden, for example, the head of the Center for 
Disease Control, had a serious injury with a lot of pain, and 
he refused to take oxycodone because he sees it as a dangerous 
drug.
    I know a great many other very well-respected doctors who 
regularly prescribe oxycodone after a serious back surgery or 
some other surgery to relieve pain, and it lasts for a few 
days. What did you do about that difference of opinion in 
Colorado?
    Mr. Valuck. Thank you, Senator Alexander. We have stressed 
in Colorado provider education and consensus building around 
evidence-based practice. Much as Dr. Wen noted, we do the same 
thing from upstream, from recommending from the very point of 
diagnosing pain to establishing treatment options to, 
ultimately, if there is pharmacological treatment of pain, that 
that might include opioids, but it might include other options 
that have also been shown to be effective for the treatment of 
acute or chronic pain.
    We recommend, as much as the Institute of Medicine has 
recently recommended that the country do, that we view pain 
much more carefully, all the way from the initial diagnosis and 
understanding of what the cause of the pain is, what the 
various treatment options are for the pain, and then to use 
best available evidence to prescribe.
    The Chairman. Do you recommend the substitutes for 
oxycodone or other such drugs that are less likely to be 
addictive?
    Mr. Valuck. We view this as a--that there should be 
options, again, for the provider and for the patient, given the 
circumstances, depending on the source of the pain, the type of 
the pain. I'm not a diagnostician, not being a physician.
    As a pharmacist, understanding the pharmacology and 
therapeutics of treating pain, there are a variety of options 
that may range from nonsteroidal anti-inflammatory drugs to 
opioid painkillers to other medications that have pain 
relieving properties, like gabapentin or some other classes of 
drugs. There's a variety of options available, and we believe 
that physicians are best placed to make those decisions with 
their patients.
    The Chairman. Thank you very much.
    Senator Murray.
    Senator Murray. Doctor Wen, you testified that part of 
Baltimore's response is ensuring adequate crisis response, and 
I'm very interested to hear more about the 24-hour phone line 
that you talked about to establish information and referrals. 
When SAMHSA Acting Administrator Enomoto testified before our 
committee in October, she noted that our healthcare system 
often lacks the resources to address the crisis situations. 
Those are critical times when patients and individuals with 
substance use disorders and their families seek help.
    Talk to us a little bit about what benefits you have seen 
from establishing your 24-hour phone line and your 
stabilization center.
    Dr. Wen. Thank you very much for the question. When I first 
came to Baltimore and we realized that this is a critical issue 
for us to work on, we looked at what were the existing 
resources, and we found five different phone lines. I called 
them. We did a secret shopper experience and tried all five 
lines. One only operated from 10 a.m. to 2 p.m. One was 9 a.m. 
to 5 p.m. One was for mental health only. One you had to know 
your own insurance.
    We realized that if it was so confusing for me, for us as 
the healthcare providers, to figure this out, that it wasn't 
going to be working for our patients who are in need of 
immediate help. There was already a 24/7 crisis line for mental 
health emergencies, which is very closely related to addiction 
as well. We combined all of our resources into one phone line.
    This phone line just started in October, so 2 months ago, 
and already we are up to nearly 1,000 calls a week. It's not 
only a resource for patients and families, but also for 
providers, because I can tell you, as an ER doctor, it is--you 
feel hopeless when you don't know what to do with your 
patients. When this patient is there looking for help, you're 
not going to be calling 20 different clinics, asking them for 
an appointment. It would be good to call a single line, and 
this line has been very effective so far.
    I do think that the crisis services are critical. We also 
then need the next step, which is once we have the services 
available, how can we connect people into treatment 
immediately. That is the connection, that using peer recovery 
specialists would be the most helpful.
    Senator Murray. Thank you.
    Dr. Valuck, you talked about prescribing guidelines. We've 
done that in my home State of Washington. Can you talk a little 
bit about why that is an important tool in combating abuse?
    Mr. Valuck. Yes, thank you, Senator Murray. We believe that 
this is one of the cornerstones of addressing this problem, to 
first gather the best available, translate into actionable 
clinical guidance for practitioners, and then to disseminate 
those broadly and achieve consensus.
    We have for years looked to Washington State and the 
University of Washington and the Agency Medical Directors' 
Group, who have been leaders in this for at least 15 or 20 
years and continue to issue those revised guidelines. We view 
those as national exemplars for how to generate guidelines and 
what they contain.
    That said, we don't think that any one set of guidelines is 
necessarily applicable to all situations. We took those, and 
within our State, modified those as we believed appropriate for 
our State, and all of our regulatory boards got on board 
together to issue these as joint guidance for Colorado.
    Senator Murray. Thank you.
    Mr. Spofford, thank you so much for coming and sharing your 
story. It was very powerful, and we all really appreciate it. 
Can you talk about what trends you are seeing on the ground?
    Mr. Spofford. Sure. The trends on the ground--they've done 
a very good job tightening up the availability of prescription 
pills up in my home State of New Hampshire, and Massachusetts 
is very close to us. It's created the opiate addicts mainly 
going to heroin. Whereas a lot of addicts were on Oxycontin and 
Percocet, they're now mostly on heroin.
    As I spoke about, the latest trend over the last couple of 
years is the introduction of fentanyl. This drug is so much 
more potent than heroin and far cheaper. Whereas a good bulk, 
10 grams, on the street of heroin is $650, they're getting this 
fentanyl for $150. They're selling bags of fentanyl that are 50 
times more potent than a bag of heroin. It looks the same, 
smells the same, and they don't tell them the difference.
    I just had a friend die on a public bathroom floor. When 
they tested the bag 3 months ago--when they tested the bag, he 
thought he was doing heroin. There wasn't any heroin in it. It 
was all fentanyl. In New Hampshire, we've had a spike in 
overdose deaths, and it's directly related to this fentanyl. 
That's really the biggest thing that's been going on.
    Senator Murray. I really appreciate that. Thank you for 
sharing that.
    I am going to join Senator Alexander on the floor as we 
debate our bill. Senator Whitehouse has agreed to take over my 
spot for me, and I appreciate it. I really appreciate all of 
you and all of our colleagues for focusing on this issue.
    Mr. Spofford. Thank you.
    Senator Murray. Thank you.
    The Chairman. Senator Collins will have the next set of 
questions, and she will chair the committee, and Senator 
Whitehouse will be the ranking member while Senator Murray and 
I go to the floor.
    Senator Collins.
    Senator Collins [presiding]. Thank you, Mr. Chairman. You 
know how much I love having the gavel in my hand.
    [Laughter.]
    As Dr. Wen mentioned, law enforcement officials throughout 
our country are often on the front lines of this epidemic. The 
sheriff of Penobscot County in Maine tells me that the intake 
room of his jail often resembles an emergency room, between the 
number of people who are drug addicted or who have untreated 
mental illness.
    In western Maine, a police chief is spearheading a program 
called Project Save Me, and it's actually modeled after the 
Angel Program which was started in Gloucester, MA. The idea 
behind this program is to encourage addicts to come to the 
police department, turn in their drugs and their drug 
paraphernalia, and then get connected with a counselor who can 
get them on a treatment path. They won't be arrested, but 
instead they'll be paired with an individual who can help them 
begin facing their addiction. Other towns in Maine are also 
testing this model.
    You each bring very different perspectives to this crisis, 
and I would be interested in hearing from each of you what more 
you think that we could do--at the Federal level, the State 
level, and the local level--to bring law enforcement and 
treatment options together. It's clear that you can't arrest 
your way out of this problem, and yet it's law enforcement that 
is having to deal with it in many cases.
    I'd like to start with you, Mr. Spofford, and then just go 
down.
    Mr. Spofford. Sure. Any efforts to support similar programs 
as the one in Gloucester and in Maine are excellent. The 
treatment community and law enforcement have been a part of 
that--I know a lot of those folks--and have done a real good 
job on their own of trying to make this happen. Perhaps some 
official policy behind it, not just the good wishes of several 
police captains or chiefs, rather.
    Another thing that is incredibly important is, believe it 
or not, as you probably know, the largest treatment center for 
substance abuse folks in the country is our Department of 
Corrections, with statistics of 85 percent of incarcerated 
people having substance use disorders. The money behind that--
from a fiscal standpoint, an average of $48,000 to $52,000 a 
year to incarcerate them with almost very minimal and almost no 
rehabilitative services for these folks getting out.
    You take an addict and you lock him up for 6 months, 1, 5, 
or 10 years, and when they get out, they will still be an 
addict. If they're not in a process of recovery, they will 
behave and act in the same ways that they always have. 
Implementing some sort of policy to bring treatment solutions 
into our jails and our prisons to prevent these people from 
coming back, and to getting out and being productive members of 
society and productive members of a recovery community is 
incredibly important.
    Senator Collins. Thank you very much.
    Dr. Valuck.
    Mr. Valuck. Thank you, Senator Collins. We in Colorado have 
been piloting various ways to engage law enforcement into the 
mix of solutions that we are crafting. One of the ways we're 
doing that is to expand take back of unused prescription drugs. 
We think this is particularly important, given data that 
suggest between 70 percent and 73 percent of people who misuse 
prescription opioid painkillers start with a prescription drug 
they obtained from a friend or family member's medicine 
cabinet.
    We view this as low-hanging fruit, that we must clear out 
unused opioids from the medicine cabinets of all citizens. Most 
people's fear is that they won't be able to get enough opioids 
so they'll save it, when, in fact, they may have the opposite 
problem. They might have too easy a time getting more. We think 
taking those drugs back and disposing of them properly is one 
of the major things that needs to happen.
    Senator Collins. Thank you.
    Dr. Wen.
    Dr. Wen. Three concepts, Senator Collins, for working with 
law enforcement. The first is making sure that we have no round 
door policies for seeking care and increasing diversion 
programs, for example, pre-arrest diversion into treatment, 
rather than incarceration.
    The second is if somebody is incarcerated, I completely 
agree that we need to be able to provide them with the care 
that they need. Yet in Maryland, just like across the country, 
if somebody is stably maintained on methadone or buprenorphine, 
we often are not able to keep them on these medications, which, 
again, we would never do for any disease. No medical society 
would condone stopping insulin, and no medical society condones 
stopping methadone or buprenorphine when somebody is already on 
those medications. Yet that often happens in our correctional 
system.
    The third is that for people leaving our jails, these are 
people who are the most vulnerable. Many of them have lost 
their health insurance. They need help. They need case 
management to get them connected with medical treatment, 
psychiatric treatment, with addiction treatment, and also with 
housing. I'd say that those are the main things to work 
together with the law enforcement colleagues.
    Senator Collins. Thank you very much.
    Senator Mikulski.

                     Statement of Senator Mikulski

    Senator Mikulski. Thank you, Senator Collins. Senator 
Collins, I have a full statement that I ask unanimous consent 
to go into the record.
    Senator Collins. Without objection.
    Senator Mikulski. Thank you.
    [The prepared statement of Senator Mikulski follows:]

                 Prepared Statement of Senator Mikulski

    I wish we didn't have to be here today. I wish we didn't 
have a persistent and growing drug epidemic in this country--
one that is ravaging our communities and killing our young 
people. But here we are. I commend Chairman Alexander and 
Ranking Member Murray for convening this important hearing.
    More Americans now die from drug overdoses than from car 
accidents. Prescription opioid painkillers like hydrocodone, 
oxycodone, codeine, morphine and methadone are increasingly to 
blame for overdose deaths. Every day 46 Americans die from 
prescription opioid overdoses. That's two deaths an hour--
17,000 annually. Heroin, an illegal opioid, is increasingly to 
blame. According to the American Society of Addiction Medicine, 
about 8,200 Americans die annually from heroin overdoses.
    Last year in Maryland, we had 578 heroin-related deaths, 
more than 25 percent higher than the previous year and more 
than double the total in 2010. Last year in Baltimore City, 303 
people died from drug and alcohol overdoses. That's more than 
the number of people who died from homicide. In Baltimore 
today, we have approximately 19,000 active heroin users and 
many more who are abusing prescription opioid medications.
    This is a very real problem in every corner of my State. 
When I went around and met with Maryland's county executives, 
every single one of them talked to me about heroin and opioid 
abuse. It didn't matter if they were Republican or Democrat, 
from an urban or rural part of Maryland, or from southern 
Maryland or the eastern shore. This is a problem across 
Maryland and across the county.
    That is why I have fought very hard as chairwoman and vice-
chairwoman of the Senate Appropriations Committee to get 
funding in the Federal checkbook to help combat this epidemic. 
In the fiscal year 2015 Omnibus, I was able to get $441 million 
for anti-heroin activities at the Department of Justice, the 
Department of Health and Human Services and at the White House.
    The money we secured in the fiscal year 2015 Omnibus gave 
grants to States and local law enforcement to investigate and 
arrest those selling heroin and illegal prescription drugs and 
reduce drug trafficking. It provided funds to States for 
prescription drug monitoring programs so States can better 
monitor and track those offenders who are doctor shopping or 
otherwise abusing prescription drugs. It ensured States got the 
money they need to expand medication-assisted treatment and 
purchase Naloxone, which saves lives by rapidly reversing the 
effects of a heroin overdose.
    I am continuing to fight alongside many people here today 
to ensure adequate funding for these programs in the fiscal 
year 2016 Omnibus.
    This is a problem that demands immediate attention and a 
comprehensive response. It won't be solved just by the Federal 
Government or just by local governments. We must come together 
and devise a multi-pronged solution working with Federal, State 
and local governments, as well as allies in the public and 
private sector.
    I look forward to hearing from the witnesses today. I want 
to hear from them about what's working and what isn't. I want 
to hear about what States and localities are doing--I know 
Baltimore City has a number of initiatives underway. I want to 
hear their ideas for how the Federal Government can be a better 
partner in these efforts.
    I look forward to hearing from our witnesses. I know we all 
share the same goal. We simply have to stem this tide. We must 
do more and we must do better to reduce drug abuse, to help 
those struggling with addiction, to keep heroin out of the 
hands of our children and to stop those who are trafficking and 
selling these dangerous drugs. We have to do better to train 
and equip those on the front lines--our doctors, our 
pharmacists, our first responders and our law enforcement 
personnel.
    With that, it is my great pleasure to introduce Dr. Leana 
Wen, Baltimore City's Health Commissioner. Since January 2015, 
Dr. Wen has been responsible for heading up the Baltimore City 
Health Department, an agency dedicated to promoting health and 
improving well-being. In this role, she has led implementation 
of Baltimore City's opioid overdose and prevention and response 
plan, which includes street outreach teams to target 
individuals most at risk, training new police officers and lay 
people on Naloxone use and launching a new public education 
campaign.
    She has not had an easy job. She directed the city's public 
health recovery efforts in the wake of Baltimore's civil unrest 
after the death of Freddie Gray. For that, the city and I are 
extremely grateful. Dr. Wen is a board-certified emergency 
physician and a Rhodes Scholar who has served as a consultant 
with both the World Health Organization and the Brookings 
Institute.
    Baltimore City is lucky to have Dr. Wen, and I'm so pleased 
she's here today to inform the HELP Committee about the efforts 
underway in Baltimore City to combat this opioid and heroin 
epidemic.

    Senator Mikulski. For our very distinguished panel, I have 
a question related to prevention. First, when we talk about 
treatment, whether it's the abstinence approach or a medically 
supported approach, That's to be determined by a clinician. In 
this country, choice often--we need choice on what works for 
that particular individual. We salute both methods. My question 
is this.
    Dr. Wen, you talked about how to respond, the great 
hotlines, stabilization centers, and all this. How do we stop 
or prevent someone from getting on heroin or opiate addiction 
in the first place? Because these are all after the fact.
    Dr. Wen. Thank you, Senator Mikulski. The first thing that 
we need to do for adults, in particular, is prescription opioid 
awareness and understanding that this is something that we can 
all do something about. I actually didn't know--my confession--
when I'm trained in emergency medicine and when I first started 
practice as well, I'm not sure that I thought about what is the 
impact of what I'm doing. Somebody comes in with dental pain or 
back pain, and it was just natural that we prescribed Percocet 
or oxycodone or something else.
    It wasn't until a patient of mine overdosed on medications 
that I prescribed him----
    Senator Mikulski. Dr. Wen, I have 5 minutes, so what's the 
recommendation?
    Dr. Wen. Thank you. I would say----
    Senator Mikulski. I don't mean to interrupt your very 
compelling story, but----
    Dr. Wen. Thank you. My recommendation for prevention is 
that we also focus on breaking the cycle as early as possible, 
specifically by providing mental health support and counseling 
and trauma support in our schools. We do crisis interventions 
relatively well in Baltimore and in other places. We at least 
have the services. We do not have screening for trauma, and we 
do not have support for every child and every parent who needs 
mental health help.
    Senator Mikulski. I want to come back to the schools. You 
just said trauma in the schools and so on. Baltimore has been 
through a gritty time, but so has Chicago, and so have other 
communities. Are you saying that our children--are we talking 
about domestic violence? Are we talking about trauma in the 
community?
    What the schools and the teachers and parents tell me is 
that for many of our children, it's like post-traumatic stress 
because of the violence around them. Is this what you're 
talking about?
    Dr. Wen. Yes, it is. I spoke recently to a group of 8-year-
olds, 10-year-olds, and every single one of them, without using 
the word, talked about the trauma that they experienced, not 
only trauma of seeing someone shot or killed in front of them, 
but also the trauma of being homeless, the trauma of being 
poor, the trauma of not knowing their parents, the trauma of 
having their caregivers being addicted to drugs. That is the 
trauma that we must recognize and treat, not only seeing people 
as the perpetrators of violence or something wrong with them, 
but rather how can we focus on preventing the trauma and then 
intervening early.
    Senator Mikulski. Mr. Spofford, you went down a really 
rough road. What would your ideas be for prevention? Because 
you talk about young people as well and children.
    Mr. Spofford. My ideas are pretty simple and direct. The 
young people today don't understand the effects of heroin, and 
they don't understand the effects of prescription opioids. When 
they're 13, 14, and 15 years old, which is what we see when 
they're being introduced to this, they don't--they think so 
narrow-sighted, that, hey, it's a party, it's--my buddy brought 
this bag over. Let's try it. Let's get high.
    What they don't know is--the information they don't have is 
in that decision, it's a game changer for the rest of their 
life, and that the addictive power of heroin, even at that age, 
is going to grab them the majority of the time and create a 
lifelong addiction.
    Senator Mikulski. You were a young adventurous guy. How do 
you intervene without seeming schoolmarmish, nanny, whatever, 
to be able to get young people to pay attention and not feel 
it's just one more thing where we're lecturing them to be good, 
to which they then often rebel against?
    Mr. Spofford. What we do in my area is myself, for a long 
time, as well as graduates of our program and other young 
people that are in recovery, carry prevention efforts into our 
local schools. It's not a clinician with a master's degree and 
20 years in the field. It's a 25-year-old that has been sober 
for a couple of years and has actually lived that and sharing 
their experience, and they have a little more cool appeal to 
them, and they'll listen to them a little easier.
    Senator Mikulski. Cool appeal. Cool appeal is good, very 
good.
    Mr. Spofford. Yes.
    Senator Mikulski. Thank you.
    Madam Acting Chair, Dr. Wen's testimony--and it's also a 
part here--the mental health needs of children are really 
significant, and we need to start really paying attention to 
what we're doing about mental health in our schools. Thank you 
for the time.
    Senator Collins. Senator Hatch.

                       Statement of Senator Hatch

    Senator Hatch. Thank you, Madam Chairman.
    I want to thank each of you for being here today. You've 
given a lot of information to us. In 2000, Senators Biden, 
Levin, and I authored the Drug Addiction Treatment Act, the 
DATA Act, which permitted physicians to apply for a license to 
prescribe buprenorphine as a treatment for opioid addiction up 
to 30 patients.
    Then, in 2006, we co-authored the Office of National Drug 
Control Policy Reauthorization Act, which would extend the 
limit to 100 patients. In August 2015, I joined with Senator 
Markey and others in a bipartisan group of 11 other Senators in 
writing to HHS Secretary Burwell to call on the agency to use 
its full authority to raise that cap on the number of patients 
that a physician can treat with medication-assisted therapies, 
including buprenorphine. HHS has announced that they're 
considering that.
    What would be your recommendation? Let's start with you 
first, Dr. Wen.
    Dr. Wen. First of all, thank you, Senator Hatch, for your 
advocacy on this important issue. Buprenorphine along with 
methadone is first-line treatment, according to the World 
Health Organization and many of our other addiction societies. 
We absolutely----
    Senator Hatch. I understand that. What would be your 
recommendation with regard to physicians?
    Dr. Wen. There is no other medication for which there is a 
cap on how many prescriptions or how many patients----
    Senator Hatch. You would take the cap off?
    Dr. Wen. I'm sorry?
    Senator Hatch. You would take the cap off?
    Dr. Wen. I would take the cap off, and I would also 
encourage other prescribers, nurse practitioners and others, to 
be able to prescribe this medication.
    Senator Hatch. Dr. Valuck.
    Mr. Valuck. Yes, Senator Hatch, we would also support 
removing the cap--anything we can do to increase access to all 
forms of treatment, including, but not limited to medication-
assisted treatment.
    Senator Hatch. We fully appreciated your testimony as a 
former user. What would your recommendation be?
    Mr. Spofford. I would not remove the cap.
    Senator Hatch. That's good.
    Dr. Wen, I understand that you have some contact with my 
home State of Utah. Your mother graduated from Utah State 
University. She's a proud graduate from there. We're really 
proud of you and your family and what you've been able to do. 
It's remarkable what a small world this really is.
    As the author of DATA 2000 and subsequent legislation that 
shaped the structure under which physicians prescribe 
buprenorphine, I'm keenly interested in ensuring patients have 
access to the treatments they need to succeed in this battle 
against heroin and prescription drug addiction.
    How have medication-assisted therapies, including buprenor-
phine, been integrated into your strategies for combating 
prescription drug abuse in Baltimore? Also, have you seen any 
need for expanded access to buprenorphine?
    Dr. Wen. Very much. Anecdotally, we have seen, Senator, 
individuals come all the way from the Eastern Shore or from 
other States asking our providers in Baltimore City to accept 
them. Of course, because of the cap, they are unable to. We 
know that the demand for buprenorphine treatment, in 
particular, far outstrips the supply that we currently have at 
the moment.
    For us, it is very important that medication-assisted 
treatment is only one part of the treatment, as you mentioned, 
that psychotherapy has to be a part of it, along with community 
resources. That's the part that currently is not being 
reimbursed by Medicaid or by, really, any other forms of 
insurance, and so we depend on State and Federal grants to get 
recovery housing, to get peer recovery specialists, and others 
and case management. That's part of our strategy.
    Senator Hatch. Those are good points. I was encouraged by 
Secretary Burwell's announcement that HHS will be taking steps 
to revise the regulations relating to the prescribing of 
buprenorphine and containing products.
    However, some view the prescribing of medication-assisted 
treatment as simply adding more opioids into circulation. As 
access to treatment such as buprenorphine is appropriately 
increased, what efforts should be made to reduce the stigma 
associated with these therapies?
    Dr. Wen. I would also hope that there is a national 
campaign that would be launched to put a spotlight on this 
issue, that addiction is a disease, that recovery is possible, 
and that we have to begin to seek treatment now. That treatment 
could include medication-assisted treatment, but, again, 
together with other community resources and psychosocial 
support that is needed.
    Senator Hatch. What is your biggest hurdle with the State 
and local level to help people obtain treatment and comply with 
their treatment plans?
    Dr. Wen. Compliance is not a problem in Baltimore City. Our 
compliance--our relapse rates for individuals who are on 
medication-assisted treatment is less than 10 percent. The main 
issue is getting access to treatment, that individuals have to 
wait weeks or months, and in that time, if they can't get 
access to treatment, they end up using drugs, because they're 
losing that high, they're addicted, and they have to have 
something to tie them over. It's getting access. That's the 
most important thing, not the retention in treatment.
    Senator Hatch. Thank you. My time is up, but I want to 
thank all three of you for being here and highlighting these 
very, very serious problems.
    Senator Collins. Thank you.
    Senator Franken.

                      Statement of Senator Franken

    Senator Franken. Thank you, Madam Chair. What an important 
hearing.
    Thank you all for your testimony, and we've seen a 
divergence in opinion on abstinence versus medication therapy. 
On another area which is on mental health and especially in 
young people and kids and looking at trauma, I couldn't agree 
more, and that's why I'm very happy that in the new ESEA bill 
that we got mental health in the schools included.
    This whole issue of providers, whether it be with alternate 
medication or with abstinence, this is a huge issue in terms of 
providers and mental health and addiction. Mr. Spofford talked 
about naloxone saving his life on a number of occasions, it 
sounds like. This was approved by the FDA first in 1971 as an 
injectable medication used primarily in hospitals to reverse 
drug overdoses. In the wake of the burgeoning opioid epidemic, 
demand for naloxone among first responders and other community 
members has soared. Unfortunately, so too has the cost.
    Dr. Wen, in your testimony, you describe how the price of 
naloxone quadrupled. In Baltimore and Minnesota, naloxone kits 
which contain two doses cost about $160 each. Healthcare 
providers and first responders are finding that they have to 
scale back their efforts or make crude calculations about who 
they will prioritize and equip with naloxone, and I don't think 
it should be this way.
    In some prescription drug cases, like the famous Turing 
Pharmaceutical, we saw a 5,000 percent increase in the price of 
drugs. More and more, we're seeing corporations make profits on 
the backs of patients.
    Dr. Wen, can you provide more information on how these 
price increases have affected your work to prevent overdose 
deaths?
    Dr. Wen. Thank you, Senator Franken. The rising price of 
naloxone is significantly, hugely impacting our work. In the 
last year alone, the price of naloxone has nearly quadrupled in 
Baltimore, which is crazy. This is a generic medication that is 
on the list of the World Health Organization's list of 
essential medications. This is available by dimes in other 
countries, so why is it that as the demand has increased in our 
country, the price has increased so much?
    For us, we have about 3,000, for example, police officers. 
We would love to be able to equip each of them with naloxone, 
but we're only able to pay for about 300, so we have to pick 
and choose which of our police officers will be getting this 
medication. Similarly, we have outreach workers who work in all 
types of places, who do home visiting, and we cannot equip them 
because we cannot afford it in the city.
    I hope that this is something that the Federal Government 
can call for an oversight hearing to find out why is it that 
the price has increased. Also to not only--we have been 
encouraged to negotiate as each individual city and State, but 
perhaps it would be helpful to have the Federal Government 
negotiate on our behalf.
    Senator Franken. This is an issue we're seeing now about 
the price of drugs going up, of pharmaceuticals going up, and 
it's something we, as a Congress, have to address across the 
board. This is a drug that saves lives. It saved one of our 
witnesses life, who gave his moving testimony. If you have 
fewer officers who are able to carry it, someone like Mr. 
Spofford could have died.
    These prices--anyone--what can the Federal Government do to 
prevent these outrageous drug price hikes? Does anyone have any 
specific ideas, or would you like to throw that back on us?
    [No verbal response.]
    That's the answer.
    The opioid crisis has hit hardest among Minnesota's 
American Indian population. Even though American Indians 
represent only 2 percent of Minnesota's population, more than 
28 percent of babies born addicted to opiates in Minnesota are 
Indian.
    Melanie Benjamin, the chair of the Mille Lacs Band of the 
Ojibwe, called the opiate crisis the single greatest threat to 
her people, to their future, when she testified before the 
Indian Affairs Committee. At the same time, that opioid crisis 
is intensifying in Indian country. There are, again, few 
treatment programs that incorporate a cultural component.
    Mr. Valuck, in your testimony, you describe how you've 
collaborated with Federal, State, and regional stakeholders to 
create tailored interventions to combat the opioid epidemic. I 
know there are a number of Indian tribes in Colorado. Have you 
engaged in collaborations with tribes, and how have you 
leveraged the input from native Americans or other underserved 
groups to develop effective culturally based interventions?
    Mr. Valuck. Thank you, Senator Franken. In Colorado, as an 
example, we have tried to identify local and regional issues 
and approaches. One example of that is in the south central 
part of Colorado, there's an area called the San Luis Valley. 
It's a six-county region that's bordered, entirely encircled, 
by large mountain ranges and requires several hours of driving 
to get outside of the San Luis Valley.
    We've worked with leaders there to help assist in their 
development of prescribing guidelines, collaborations with 
schools and other community agencies, tapping into the 
resources of the Area Health Education Center, or AHEC system 
that exists around the----
    Senator Franken. This is tribal land?
    Mr. Valuck. This is not tribal land, but, again, it's an 
example of where we're trying to develop a local solution for 
this particular community that's largely a migrant, 
agricultural community in Colorado, to develop solutions that 
work in that specific area.
    Senator Franken. OK. I'm very sorry, Madam Chair, that I've 
gone well over my time. We'll get back----
    Senator Collins. We do have a vote at 11:30, so I want to 
make sure everybody gets time. Thank you.
    Senator Franken. I apologize. Thank you for your 
indulgence.
    Senator Collins. Thank you.
    Senator Scott.

                       Statement of Senator Scott

    Senator Scott. Thank you, Madam Chairwoman.
    Thank you to the panelists for being here today.
    Dr. Valuck, in South Carolina, we certainly are seeing what 
I consider an epidemic. I think's it's from 2012 to 2014, we 
had about 8,000 patients who were treated in the emergency room 
about 10,000 times for opioid dependency. We had about 2,500 
patients who were treated 3,000 times in the ER for overdose. 
We've certainly seen a real campaign for the crackdown on over-
prescribing.
    The question I have is how do we, on the front end, prevent 
this rising challenge from occurring in the first place? 
Certainly, I know we look at how we treat addiction in the 
aftermath. My question really is are there key signs or things 
that we can do to help prevent it on the front end?
    Mr. Valuck. Thank you very much, Senator Scott. We believe 
that prevention hinges on doing education, both broadly--the 
general awareness of the public and the provider communities--
but moving most of our educational efforts to those who are 
youth and young adult age, knowing where things start and what 
the consequences are that you point out.
    We are advocating for increased SBIRT-like approaches--
screening, brief intervention, and referral--in the school 
systems, and, last, focusing on--in our next wave of block 
grant money, focusing on positive youth development approaches 
in Colorado, shifting away from shaming and blaming kinds of 
approaches to positive youth development as alternatives to 
substance use, and we believe that's where the prevention 
activities will be best and most successful.
    Senator Scott. Thank you. To the panel--and I'll start with 
Mr. Spofford--in South Carolina, we had about 516 people die in 
2014 because of overdose. Around 2008, we only had about 250 
folks die. We've seen an explosion in the deaths.
    What can we do better, and what tools outside of treatment 
for addiction should we be looking for to address some of the 
challenges? My previous question to Dr. Valuck about how we on 
the front end eliminate this as the reality that we're seeing--
how do we do that?
    Mr. Spofford. As it concerns the explosion and overdose 
deaths, fatalities, that your State has had, so has ours. I 
would assume that it's probably somewhat safe to say that 
that's directly related to the fentanyl. Increasing those 
sentencing laws for fentanyl and force--as sad as this may 
sound--forcing those drug dealers back into actually selling 
heroin and not something that's killing as many people is the 
first round.
    Increasing the naloxone availability to prevent deaths--if 
you're talking solely on how to prevent people from dying from 
opioid addiction, fentanyl is killing people. Very rarely do 
you see anyone die from heroin and heroin alone. It's a 
combination of heroin and other drugs that has been what we've 
seen the most for overdose deaths in past years, and then 
recently with this upward spike of overdose is the fentanyl.
    Senator Scott. Last question. There's a rule of nature in, 
of course, Colorado, New Hampshire, and South Carolina, so 
access to treatment is very difficult. Do you see bridges to 
take care of that problem or at least mitigate the concerns 
that we have in the rural areas of our States? Anyone on the 
panel?
    Dr. Wen. Thank you very much, Senator Scott. Even though I 
don't practice or work in a rural area, we still have many 
challenges in our urban setting of not having enough access. 
That's why we are proponents for allowing cities and States 
that know their own jurisdictions the best opportunities to 
innovate, including with telemedicine and telehealth.
    There might be opportunities to work within ERs to do rapid 
buprenorphine induction within the ER setting. There might be 
other opportunities to work with peer recovery specialists and 
other models that may work best for those settings. We hope 
that those models will also be explored for potential funding 
and then Medicaid reimbursement.
    Senator Scott. Any other comments?
    Mr. Spofford. Yes, to increase access to treatment. In my 
home State of New Hampshire, if you have Medicaid insurance, 
you're looking at a 4- to 8-week wait list to get a bed in a 
residential program. The reason for that is because of the day 
rate of the reimbursement for Medicaid. It's, quite frankly, 
unreasonable.
    I ran a pro-forma for my own treatment center, and if I 
kept all of my beds filled with Medicaid reimbursements, it 
would cost me twice the amount of the income that would come 
through the door to be reimbursed. Maybe examining the 
reimbursement rates for the day rate of treatment would 
encourage treatment providers to open up more availability.
    Senator Scott. Thank you.
    Thank you, Madam Chairwoman.
    Senator Collins. Thank you.
    Senator Baldwin.

                      Statement of Senator Baldwin

    Senator Baldwin. Thank you. I very much appreciate our 
Chairman and Ranking Member for holding this hearing and our 
Acting Chairman and Ranking Member for continuing it and our 
witnesses today.
    Certainly, in the State of Wisconsin, we are experiencing 
the epidemic, both with regard to prescribed opioids and 
heroin. I wanted to just briefly mention that what has been 
particularly troubling to me in our State is the dangerous 
misuse of opioids in treating veterans at some of our VA 
facilities, including the VA hospital in Tomah, WI, where 
Marine veteran Jason Simcakoski passed away while in inpatient 
treatment of mixed drug toxicity.
    His story and his family's willingness to turn tragedy into 
action inspired me to author the Jason Simcakoski Memorial 
Opioid Safety Act with Senator Capito of West Virginia to 
reduce the misuse of opioids and improve pain management 
training among practitioners who care for our Nation's 
veterans. We hope, in another committee, to see that measure 
advance forthwith.
    I hope to get to several questions, so I ask for your 
answers to be as brief and specific as possible. With regard to 
access to opioids through prescriptions, you've talked a lot 
about databases and monitoring. You've talked a lot about 
improving the education and preparation of our prescribers.
    I am interested in knowing the impact you think that the--
what they call the fifth vital sign--that adding to the pulse, 
the blood pressure, respiration, and temperature, that there 
would be an assessment of every patient's pain level--what 
impact that had on our rising rates of prescriptions of opioids 
and this epidemic.
    Dr. Wen. Senator Baldwin, unfortunately, that had a huge 
impact on physicians' understanding of pain and also patients' 
treatment of pain. Getting pain free is not necessarily the 
right outcome. If you fall down and you bruise your knee, 
you're going to have pain.
    For us to say the goal is to take your pain to a 0 out of 
10, what does that mean? Or also even if a patient comes in 
with 10 out of 10 pain, but they're texting on their phone--
what does 10 out of 10 pain mean? It is important for us to 
discuss what our policy metrics should be that do take into 
account adequate treatment of pain but don't make that the 
single focus.
    Senator Baldwin. Any other comments on that question before 
I move on?
    [No verbal response.]
    I wanted to dig a little bit more deeply into things that 
I've been reading about use of methadone in treatment of 
addiction. As I understand the drug--and I am a lay person in 
terms of my reading--the sort of high or the euphoric effects 
of methadone wear off more quickly than the respiratory 
depressant impact of methadone, that that lasts longer and, 
therefore, that has some real implications in the medicine-
assisted treatment of abuse.
    We have actually--according to the CDC, methadone accounts 
for only 2 percent of prescription painkillers, but is 
responsible for a significantly higher number of overdose 
deaths. Where does that fit in with some of the other drugs 
that are being used in the treatment of addiction?
    Dr. Wen. I wish to distinguish between the use of methadone 
for pain and the use of methadone for medication-assisted 
treatment for opioid addiction. For pain, it is true that 
methadone has a high risk of overdose, and because of them--and 
also there are effects, the euphoric effects and so forth, that 
then lead to methadone being abused as a recreational drug.
    On the other hand, individuals who are on long-term 
medication-assisted treatment, including with methadone or 
buprenorphine, are stably maintained, and so they do not 
experience the high. That said, individuals on buprenorphine 
have a much lower rate of overdose than individuals who are on 
methadone. This is the reason why we believe that buprenorphine 
access should be encouraged.
    Senator Baldwin. It would be interesting to see--I don't 
know if the CDC has a breakdown of what the initial 
prescription of methadone was for, whether for the medically 
assisted treatment or the pain.
    I have one last question I want to get into the record for 
followup. I'm very interested in knowing about the shocking 
uptake in fentanyl abuse and where it's coming from. Is this 
being diverted from prescriptions? Is this something that 
people are bringing in illegally? What are the sources?
    Mr. Spofford. It's being brought in illegally and cooked in 
underground labs by Mexican cartels.
    Senator Whitehouse. A question for the record means you all 
have the opportunity to answer in writing.
    Senator Collins. I should have explained that. Thank you.
    Senator Cassidy.

                      Statement of Senator Cassidy

    Senator Cassidy. Thank you all. I have several questions. 
I'm a physician, so I'm going to take this--we want actionable 
items. We want to think about something that we leave from here 
and we can say, ``Wow, this is something that maybe 
legislatively we can do.''
    Mr. Valuck, Congress in the past has appropriated lots of 
money for prescription drug monitoring programs, where every 
doc, theoretically, who writes a controlled substance, it goes 
into a database. The pharmacist can see--``Oh, my gosh. Is this 
person doctor shopping, getting prescriptions from everybody 
else?''
    I've learned recently, though, that VA facilities do not 
automatically integrate into such databases, nor do necessarily 
neighboring States. To what degree are you all using in 
Colorado the PDMPs? What is their usefulness, and what can we 
do so that the VA in Denver, if it's ever built, can actually--
the provider can seamlessly know whether or not the 
prescription that he or she is prescribing is for someone 
doctor shopping, et cetera?
    Mr. Valuck. Thank you very much, Senator Cassidy. Yes, we 
view PDMPs as a crucial tool in the fight against prescription 
drug abuse. The things we have achieved through just mandatory 
registration, where every provider and prescriber and 
pharmacist must have an account, has even within 1 year gone 
from 20 percent to 94 percent----
    Senator Cassidy. Do you mandate that every controlled 
substance prescribed and filled is put into the database?
    Mr. Valuck. Yes. Everything must be in the database, and--
--
    Senator Cassidy. If someone is in a neighboring State and 
not licensed in Colorado, can they access that PDMP?
    Mr. Valuck. There are two ways they can do that. One, they 
may apply for an account with our PDMP and be granted one 
through our Department of Regulatory Agencies. To the extent 
that States are now increasing their participation in the NABP 
Interconnect program, which is a sharing program, about 22 or 
23 States are now sharing data and going through a single hub 
to be able to access this on a multistate basis. More and more 
States are joining because----
    Senator Cassidy. What about the Veterans Administration? 
Are they automatically in your system?
    Mr. Valuck. We passed enabling legislation, but as a State, 
we could not--obviously, we could not require that they report.
    Senator Cassidy. On a Federal level, if we, at a Federal 
level, had the VA granted access, provided those resources, 
that would be something tangible we could do to benefit those 
patients. Fair statement?
    Mr. Valuck. That would help, yes.
    Senator Cassidy. Mr. Spofford, I am struck. You've got 
frontline therapy of a guy that knows how people get drugs. 
These are controlled substances. A physician is writing the Rx. 
Tell me that process--and we have a short period of time. If I 
interrupt, I don't mean to be rude.
    Mr. Spofford. Prescription?
    Senator Cassidy. Correct.
    Mr. Spofford. Most recently, things have moved down to 
south Florida. They have pain pill mills. If you drive through 
from West Palm Beach to Miami, almost on every corner you'll 
see a pharmacy----
    Senator Cassidy. In Florida, they're getting the pills and 
they're bringing them all the way to New Hampshire?
    Mr. Spofford. There's crews of kids and drug dealers that 
take trips with fake MRIs and go down and doctor shop--20 
doctors, 20 pharmacies, none of which are connected in southern 
Florida. They take the trip once a month and flood the streets 
of New England.
    Senator Cassidy. Going back to you, Mr. Valuck, if we have 
this PDMP, you should be able to do a frequency analysis and 
see which docs are prescribing, because I have to put my DEA 
number every time I write an Rx, a prescription. You should be 
able to use that database to say, ``This doctor is prescribing 
in the third standard deviation. Let's investigate that doctor, 
in particular.'' Is that what is done in Colorado, or do you 
leave that up to DEA?
    Mr. Valuck. That, we leave up to DEA or complaints, or law 
enforcement can have access to the database, but only pursuant 
to a subpoena or a court order to do that. We have the concern 
that there may be physicians that are doing what you said and 
doing so in a way that would be considered inappropriate. There 
may be pain physicians who are treating a large number of 
patients.
    Senator Cassidy. I accept that, but when I write my 
prescription, they know whether I'm an oncologist, a pain 
doctor, or whether I just happen to be an FP, and they also 
know if I'm licensed in four States, and I'm rolling between 
them.
    Mr. Valuck. To some extent, but the specialty information 
is sketchy, and varies State by State.
    Senator Cassidy. I always think that if Google had this 
information, they'd be able to figure it out in about 3 
minutes, and I'm probably being unfair to Google. It does seem 
as if this is something DEA should do. If we are going to--if 
all you've got to do is look on a controlled substance database 
and figure out who is writing two prescriptions a minute and 
whether or not they're a pain doctor or an oncologist or not, 
it seems like we should be able to do so.
    I yield back. Thank you.
    Senator Collins. Thank you.
    Senator Warren.

                      Statement of Senator Warren

    Senator Warren. Thank you, Madam Chair.
    The opioid epidemic is a health crisis. In Massachusetts 
alone, there were more than 1,000 confirmed opioid-related 
overdose deaths in 2014. That is a 63 percent increase from 
just 2012. Fighting this epidemic will take smart, creative 
ideas like the efforts of Chief Campanello of the Gloucester 
Police Department. They have an Angel Initiative that ensures 
that anyone who enters the police station and asks for help 
with drug addiction receives it without getting arrested.
    Dr. Wen, how does this type of initiative save both our 
justice system and our healthcare system money and at the same 
time save lives?
    Dr. Wen. Thank you, Senator Warren. Chief Campanello 
actually just came to visit us in Baltimore yesterday----
    Senator Warren. Oh, good.
    Dr. Wen [continuing]. And so we had a chance to learn about 
his approach. We know that addiction is a disease. We know that 
we're not going to be arresting our way out of it, that we also 
have to provide treatment. Providing this no round door, 
decreasing barriers into treatment, is critical. I very much 
applaud the initiatives in Massachusetts.
    I wish to add, though, that there are two other components, 
which is that there must be enough treatment options so that 
when somebody comes to the police department or the ER or 
somewhere else for help that they must also be connected into 
treatment at that time, immediately, not wait 3 weeks or 4 
months or something, but be connected immediately, and also 
that there are continued community support services that are 
also reimbursed, that we must be reimbursing our community 
health workers at the rate that they deserve, and also that we 
must have reentry services and housing and other support that 
is critical for individuals with addiction.
    Senator Warren. Good. Excellent points, but we've got a 
good entry point here with the Angel Program. This Gloucester 
program is a great example of local leaders understanding what 
it takes to treat substance use disorders on the ground. It 
takes hard, compassionate work by law enforcement, by medical 
professionals, and by members of the community.
    The Federal Government also needs to help here. For 
example, the National Institute on Drug Abuse estimates that 
over 70 percent of adults who misuse prescription opioids get 
the medication from friends or relatives, meaning many patients 
receiving these prescriptions aren't using all of the 
medications that were prescribed for them. States like 
Massachusetts are considering policies that would allow opioid 
prescriptions to be dispensed by pharmacies a few days at a 
time--it's called a partial fill--so that patients don't 
receive more drugs than they will actually use.
    Professor Valuck, how could the use of partial fill 
policies help to prevent opioid misuse and abuse?
    Mr. Valuck. Thank you very much, Senator Warren. We believe 
that all policies related to prescribing and dispensing of 
opioids should balance the desire and the need now to reduce 
abuse, misuse, and diversion, while at the same time not 
putting up barriers for people who have legitimate medical need 
for those drugs.
    It becomes, in our view, an issue for the physician and the 
pharmacist to determine what is appropriate at the time for 
that patient to receive, and that it may not be something that, 
for any given patient, we can say what that optimal quantity 
might be.
    Senator Warren. What we're looking for here, obviously, is 
to have fewer loose drugs around. Current DEA regulations are 
silent on whether partial fills are allowed outside long-term 
care facilities or an acute pharmacy shortage. States that want 
to implement these policies don't know for sure if they're 
legal. I'll be sending a letter to the DEA with Senator Markey 
to request that the agency clarify these regulations.
    It is important to reduce the amount of unused medication 
out there, and that means people also need to know how to 
dispose safely of their excess opioids. But here's a problem. 
The FDA, the EPA, and the DEA all have different 
recommendations on how to do this. While all the agencies 
highlight that the ideal plan is to take them to a police 
station or pharmacy for collection, there are varying 
recommendations about whether or not to throw them in the 
trash, the best way to do so, whether to flush them down the 
toilet, and so on.
    Dr. Wen, can you clarify how people should dispose of their 
unused drugs?
    Dr. Wen. Thank you, Senator Warren. The answer is do not 
flush it down the toilet, don't throw it in the trash can, but 
take it, ideally, to a permanent drop box. We just implemented 
in Baltimore City a couple of weeks ago, actually, nine 
permanent drop-off areas all at our police stations across the 
city. They are 24/7, no questions asked, which is critical 
because you do not want to be arrested while you're bringing 
these drugs back.
    I also want to emphasize that this is not only important 
for prescription opioids, but also for any medications. I've 
seen 2-year-olds take their grandparents' high blood pressure 
medications or insulin and also overdose on those and die as 
well.
    Senator Warren. I thank you very much for that answer. 
Federal agencies need to coordinate----
    Senator Collins. Senator Warren, I apologize for 
interrupting you, but the vote has started. You're over your 
time, and we still have two more people. My apologies.
    Senator Warren. That's quite all right.
    Senator Collins. Let me say that the hearing record will 
remain open for 10 days, and if members have additional 
information or questions for the record, they can submit those.
    Senator Casey.

                       Statement of Senator Casey

    Senator Casey. Madam Chair, thank you. I'd ask consent to 
submit a full statement for the record.
    Senator Collins. Without objection.
    Senator Casey. Thanks very much.
    [The prepared statement of Senator Casey follows:]

                  Prepared Statement of Senator Casey

    Thank you, Chairman Alexander and Ranking Member Murray, 
for holding a hearing today on this critical issue. Opioid 
abuse is a crisis that is engulfing families, public health 
professionals and law enforcement throughout the Nation. Right 
now, my own State is a national leader where we don't want to 
be--in the number of drug overdoses occurring each year. 
According to the Drug Enforcement Agency, Pennsylvania ranks 
ninth highest for drug overdose deaths in the Nation, at a rate 
of 18.9 per 100,000 people. According to the Centers for 
Disease Control and Prevention, more Pennsylvanians now die 
from drug overdoses than car accidents.
    Prescription opioid and heroin abuse is not limited to 
certain kinds of communities, a fact that is illustrated both 
by reports in the national media and hard data gathered by law 
enforcement agencies. An August 23 headline from the Washington 
Post, focusing on events in Washington County, PA, read ``The 
Heroin Epidemic's Toll: One County, 70 Minutes, Eight 
Overdoses.'' The article describes how, in a period of just 
under 70 minutes, there were eight overdoses in a county of 
about 200,000 people. In 24 hours there were 16 overdoses. In 2 
days, there were 25. Three people died. Meanwhile, a recent DEA 
report for Pennsylvania included a county-by-county summary of 
overdose deaths per 100,000 people. Although these statistics 
relate deaths from all drugs, heroin is a major contributor. 
What strikes me about this data is that the largest number of 
deaths are in Philadelphia, Susquehanna, Cambria, Fayette and 
Wayne counties. Although Philadelphia County is urban, the 
other four counties are mostly rural or made up of small towns. 
This is the nature of the problem, in Pennsylvania and 
throughout the country.
    There is no simple solution or law that Congress can pass 
to fix this problem, but there are commonsense steps that we 
can take to identify and attack the roots of the opioid crisis 
in this country. I am a cosponsor of several pieces of 
legislation that would move us in the right direction. These 
include a bill called the TREAT Act, introduced by Senator 
Markey, that would expand the ability of physicians and nurse 
practitioners to prescribe buprenorphine, which is used to 
treat opioid addiction, as well as another of Senator Markey's 
bills, the Treatment and Recovery Investment Act, which would 
increase funding for the Substance Abuse Prevention and 
Treatment Block Grant. I am also a cosponsor of legislation 
introduced by Senators Toomey and Brown that would prevent 
doctor and pharmacy shopping for at risk Medicare 
beneficiaries.
    Congress has already taken one important step by passing 
the Protecting Our Infants Act, and I am grateful to this 
committee for moving quickly on the legislation. I am pleased 
that the Protecting Our Infants Act, which I introduced with 
Senate Majority Leader Mitch McConnell, was recently signed 
into law. This new law will address one of the tragic 
consequences of the opioid epidemic, the growing incidence of 
Neonatal Abstinence Syndrome, which occurs when infants are 
born in withdrawal from opioids taken by their mothers. The law 
requires the Department of Health and Human Services to develop 
a strategy to address research and program gaps on prenatal 
opioid use and Neonatal Abstinence Syndrome. However, although 
passage of this legislation promises to be a critical 
achievement for helping infants born in withdrawal, I am also 
aware of ongoing concerns around States' implementation of 
Plans of Safe Care for these infants under the Child Abuse 
Prevention and Treatment Act. I hope that this committee will 
take steps to address these concerns as part of our larger 
strategy on opioid abuse.
    Far too many of our local communities are struggling 
against the rising tide of prescription opioid and heroin 
abuse, and far too many families are being torn apart. I look 
forward to hearing from the witnesses on how we can combat 
opioid abuse in my own State and throughout the Nation.

    Senator Casey. Like a lot of States that we've highlighted 
today, Pennsylvania is not immune. In fact, unfortunately, the 
problem has gotten as bad in Pennsylvania as probably anywhere 
in the country, most of it heroin. Maybe one headline would 
summarize it. This is a headline from the Washington Post, but 
it's about Washington, PA, the headline reading, ``The Heroin 
Epidemic's Toll, One County, 70 Minutes, Eight Overdoses.'' 
Then it goes on to tell how many overdoses within a 24-hour 
period. Three of them were deaths.
    Looking at a summary of various county data in 
Pennsylvania, what struck me about the number per 100,000 in 
terms of deaths--these are drug-related deaths--I realize a 
larger category--but most of them, in fact, the top five, I 
believe, are all heroin. It starts with Philadelphia, which 
fits a stereotype that it's a big city problem. The next four 
counties, Susquehanna, Cambria, Fayette, and Wayne are all 
small counties, substantially rural, and where it's not rural, 
it's mostly small town. This is the nature of it in a State 
like ours, and I know that's true across the country.
    I'll start with Mr. Spofford. I want to ask you about young 
people and kind of your message to them. The first question is 
more technical, about insurance providers. I'm told that 
insurance providers often fail to reimburse stays at inpatient 
treatment facilities in a way that allows professionals to meet 
their standard of practice for treating their patients. Have 
you run into this issue of insurance coverage for that kind of 
treatment?
    Mr. Spofford. Almost every day.
    Senator Casey. That's something that we've got to address. 
Any recommendations you want to send to us or transmit to us, 
we'd appreciate that.
    The second part--and only because we're--I'm going to go 
less than my time, probably, because of the vote. Young 
people--you went down a path that you described here today, and 
I can't even imagine how horrific it was. What do you say to 
young people? Or if you had a group of young people in front of 
you today who have started down that path, especially as it 
relates to the use of Oxycontin or something similar, what 
would you say to them?
    Mr. Spofford. If it was pre-use or no addiction was 
present, the education of what that path consists of and the 
addictive power of prescription opioids and heroin is 
incredibly important. For anyone who has started using, just 
conveying the message that hope is absolutely available and 
people do recover, we do get better, that sobriety and recovery 
is achievable.
    Senator Casey. If they've started on Oxycontin, where 
should they go? What should be their first step if they're 
listening to you?
    Mr. Spofford. Treatment.
    Senator Casey. Treatment?
    Mr. Spofford. Yes. By that time, it's gone too far. It's a 
bigger problem than most people realize, and they really need 
to be in treatment.
    Senator Casey. Thank you.
    Dr. Valuck, I wanted to ask you--and, Dr. Wen, I might have 
to submit yours for the record. When you were developing best 
practices in connection with the provider education work group, 
were you able to determine, or did you attempt to determine 
this fundamental question, which overlays all of this, which is 
the question about physicians, why some physicians are over-
prescribing various opioids?
    Mr. Valuck. Thank you, Senator Casey. We, again, have tried 
to take an evidence-based approach and move to a discussion 
where we know we're downstream now, dealing with consequences, 
and trying to shift the discussion upstream to not only proper 
choices and what are the choices for prescribing, but how is 
pain better recognized and diagnosed and framed, as Dr. Wen 
duly noted. We're trying to move the discussion upstream into 
the decisionmaking about what the pain is, how pain can be 
treated in various ways, what the expectations would be, and to 
try to better manage expectations to deliver better care.
    Senator Casey. Thank you very much.
    Senator Collins. Thank you very much.
    Senator Whitehouse, I'm going to tell you that we have 3 
minutes left in the vote, so if you don't mind, I'm going to 
thank our witnesses and allow you to ask your questions and 
close out the hearing without me.
    Senator Whitehouse. Subject to my questions, that's fine. 
I'm happy to close it out.
    Senator Collins. Thank you. I appreciate that, never having 
missed a vote.
    Senator Whitehouse. Yes, you should not. Please go.
    Senator Collins. Thank you to our witnesses.
    Thank you, Senator.

                    Statement of Senator Whitehouse

    Senator Whitehouse [presiding]. As I think everybody has 
said about their home States, Rhode Island is seeing this 
plague--239 deaths in 2014, which is more than homicides, more 
than suicides, more than car wrecks, indeed, more than all of 
those things combined. We're focused on this.
    One of the areas where we could be helpful in this 
committee is to look at the problem of the coordination of 
prescription drug monitoring programs. Each State has one. They 
have very different funding sources. They have very different 
rules. Access to them is to very different groups. Prescribing 
practices are extremely helpful, but I also think some 
monitoring is important.
    What would your suggestions be for getting some degree of 
commonality and some better coordination between different 
States' prescription drug monitoring programs? I say this as 
one of the 16 States that received the grant, and I hope that 
executive process will encourage better collaboration and 
coordination, but there's stuff we could do as well.
    Dr. Wen, you first, then Dr. Valuck, then Mr. Spofford.
    Dr. Wen. Thank you, Senator Whitehouse. I'd like to add my 
perspective as a practicing emergency physician, as well, one 
who has used our PDMP in different States, to talk about what 
the barriers might be. In theory, PDMP--all physicians support 
the idea. We would love to be able to look up the PDMP----
    Senator Whitehouse. Every State is different, and they 
don't talk to each other well.
    Dr. Wen. That's right.
    Senator Whitehouse. How do we fix that problem?
    Dr. Wen. I would, first of all, make each State's PDMP easy 
to use and have one place--ideally, one click would get us to 
one national database instead of having--I used to practice in 
DC Looking up Virginia and Maryland and DC was a lot, so having 
one national database. Ease of use is important.
    The second thing is that most physicians are not doing bad 
things. We're not doing pill mills or other things. We actually 
don't know what our own prescription practice is. What we're 
beginning to do in Baltimore City is, looking at the high 
prescribers and sending them letters. Or if there are patients 
who have died who have received----
    Senator Whitehouse. Yes. I really want to focus on the 
question of coordination among the States, because that's 
really where we can be most useful.
    Dr. Valuck.
    Mr. Valuck. Thank you, Senator Whitehouse. We support and 
would really love to see additional Federal support for 
interoperability and for physicians to be able to query, again, 
across multiple States. Some of the models that are happening 
now are collaborative and voluntary. We'd like to see some sort 
of way that when a physician queries or a pharmacist queries 
the database that they are getting an all 50-State query, 
whether that's a national database or a connected network of 
all 50.
    Senator Whitehouse. Should we be reviewing whether 42 CFR, 
Part 2, and its privacy provisions are an impediment to 
coordinated care?
    Mr. Valuck. To the 42 CFR, Part 2, question, that is a very 
difficult one. We absolutely want to protect patient privacy 
and the data, but we also want to----
    Senator Whitehouse. We also want to coordinate----
    Mr. Valuck [continuing]. Encourage coordinated care and 
being able to do that. We have found in Colorado that 
physicians and other providers don't well understand what is 
and isn't permissible under 42 CFR 2 and tend to take an 
approach of if there's a question, we'd rather not share and 
potentially risk anything. It may be hindering the cooperation 
that we want to have happen. Clarification about 42 CFR for 
physicians would be very helpful.
    Senator Whitehouse. Mr. Spofford, congratulations on your 
sobriety. I guess yesterday was your anniversary--so 9 years.
    Mr. Spofford. Thank you.
    Senator Whitehouse. It's amazing what you've accomplished 
in 9 years, because I doubt you were accomplishing a lot of 
this pre-sobriety, right?
    Mr. Spofford. That's right.
    Senator Whitehouse. Tell me a little bit--you run these 
facilities. You've got to be reimbursed. You touched on it 
briefly. We've tried in Congress to get mental health services, 
which include addiction services, treated more in parity with 
traditional physical health services. Do you feel you're 
getting paid and reimbursed in a way that is commensurate with 
people who are in other healthcare areas?
    Mr. Spofford. No, not at all. A standard of what's 
medically necessary for the treatment of substance abuse would 
be incredibly helpful. One definition that we adhere to--we see 
things like this. We have, say, a 22-year-old heroin addict 
that's been an IV user for 3 or 4 years, and before he's able 
to receive inpatient treatment, the insurance company will say 
that he needs to fail at outpatient first. I've seen people die 
failing at outpatient. Continually arguing to get these----
    Senator Whitehouse. It's hard to imagine that taking place 
in a physical health setting, isn't it?
    Mr. Spofford. Yes, it's a little different. Then once we 
have them in the inpatient treatment, it's a day-in and day-out 
fight to get more days authorized.
    The insurance company approves the initial authorization, 
and we get a person admitted into treatment. It then becomes 
this cat-and-mouse game of utilization review, fighting for 
more treatment, fighting for our patient to keep them engaged, 
with some case manager who has never even laid eyes on our 
patient trying to dictate their treatment and when they need to 
discharge and what's medically necessary for them over and 
above our clinician, our nursing staff, our docs, and things 
like that.
    They'll cut treatment at 7 days. This kid's been on the 
street shooting heroin for 5 years. What are we going to do in 
7 days?
    Senator Whitehouse. It's pretty much industry standard that 
30 to 60 days is necessary, correct?
    Mr. Spofford. Should be.
    Senator Whitehouse. OK. Listen, time has run out. I'm the 
last person here. The vote is winding down. I've got to dash.
    I really do thank you all for your testimony. I would ask, 
for the record, if you have the time and inclination, look at 
the Comprehensive Addiction and Recovery Act, which I have co-
authored along with a great number of candidates. If you'd like 
to make any comments back about that bill, please take 
advantage of this opportunity to do so.
    I know it's not in this committee. It's in the Judiciary 
Committee, and we are hoping to get a hearing on it early next 
year in the Judiciary Committee and be able to move forward. 
I'm sure your advice would be helpful.
    Thank you all very much. The hearing record will remain 
open for 10 days. Members may submit additional information for 
the record within that time if they would like.
    The committee is adjourned.
    [Additional Material follows.]

                          ADDITIONAL MATERIAL

  Response by Leana Wen, M.D. to Questions of Senator Casey, Senator 
     Franken, Senator Bennet, Senator Whitehouse and Senator Warren
                             senator casey
    Question 1. It sounds as though Baltimore is working hard to solve 
its opioid abuse epidemic, and I appreciate your efforts. As we are all 
aware, however, this epidemic, and the problems that are created by it, 
can easily cross local and State boundaries. What challenges has 
Baltimore faced when working with other local communities to stem the 
tide of opioid abuse? Are there common cross-jurisdictional hurdles 
that the Federal Government can help overcome?
    Answer 1. Thank you for your recognition of our efforts here in 
Baltimore City. Our approach to the opioid abuse epidemic is evidence-
based and comprehensive, and necessitates that we focus not only on 
what is achievable here in our city but also the multitude of local, 
State, and Federal-level factors that contribute to opioid use 
nationwide.
    Naloxone accessibility and cost. One core challenge we face at the 
community level is naloxone accessibility, which varies even within a 
single city jurisdiction. Naloxone is a generic medication that is part 
of the World Health Organization's list of essential medications, but 
pharmacies vary in their stocking methods and sometimes do not fulfill 
prescriptions for this life-saving antidote. Additionally, the price of 
naloxone has dramatically increased over the past 2 years--in Baltimore 
alone, the cost per dose of naloxone has quadrupled--meaning that we 
can only save a quarter of the lives we could have saved.
    This is particularly problematic for cities and counties that must 
purchase naloxone for use by paramedics, police officers, and other 
front-line workers. Manufacturers have claimed that this price increase 
is related to increased demand. However, it is unclear why the cost of 
a generic medication that is available for much lower costs in other 
countries will be suddenly so expensive. These challenges are not 
unique to Baltimore, and Congress can help overcome this obstacle by 
calling for investigation into the reason for the price increase. 
Additionally, the Federal Government should remove barriers that 
prohibit easy access to naloxone: for example, by making it available 
as an over the counter medication that is covered by both private and 
public insurance.
    Access to treatment. Regardless of jurisdiction, we need to ensure 
that there are sufficient high-quality treatment options available to 
those suffering from opioid addiction. There are several ways that the 
Federal Government can impact access to treatment:

     Federal funding could expand treatment on-demand including 
24/7 dedicated centers for substance addiction and mental health and 
proven intervention models such as LEAD and expand case management 
services for vulnerable individuals. These programs will help to ensure 
that those in need have a path to recovery.
     Congress can push for equitable insurance coverage for 
addiction services. Medicare pays for pain medications that can lead to 
addiction, yet many States do not cover medication-assisted treatment 
and other evidence-based interventions for addiction recovery. Congress 
can ensure that Medicaid, Medicare, and private payers cover on-demand 
treatment for acute care (such as sobering, urgent care, and 
residential services), as well as ongoing treatment and services like 
medication-assisted treatment and case management. These rates should 
also be equivalent to mental health and physical health care rates 
(which they are not currently, leading to a dearth of providers and 
inadequate care).
     Congress can remove barriers to prescribing Buprenorphine. 
Buprenorphine is a medication-assisted treatment option with a much 
lower chance of overdose than methadone. Importantly, it can be 
administered by a primary care provider rather than in a designated 
drug-treatment clinic. This helps to increase the accurate perception 
that substance use disorder is a medical condition. Unfortunately, at 
the moment, only medical doctors can prescribe buprenorphine, and a 
doctor can only provide Buprenorphine to a maximum of 100 patients. 
This barrier does not exist for any other medication, and significantly 
limits the ability of patients to access a life-saving treatment option 
and leaves many patients with methadone as their only option for 
medication-assisted treatment. Methadone requires administration in a 
designated treatment clinic, which are often a point of contention 
within the communities in which they operate due to the stigma 
associated with drug addiction. We strongly support current efforts 
underway at the Department of Health and Human Services to revise the 
limits on buprenorphine prescription in a given year, and urge further 
support of broadened access 8 to this proven treatment including by 
requesting Congress to consider broadening prescription authority of 
Buprenorphine to Nurse Practitioners and other providers.

    Crisis response. One of the biggest hurdles in the behavioral 
health system is the necessity of developing a full range of integrated 
crisis response services that divert people away from a criminal 
justice response and/or high cost inpatient services. The crisis 
response system serves as a major access point in the overall public 
behavioral health system. Because crises are defined by individuals and 
are also the point in time when individuals could be most willing to 
accept treatment for substance use disorder, having a 24/7 crisis 
response system is a critical component of ``treatment on demand''. 
However, the majority of crisis response services are not reimbursable 
by Medicaid. Federal action to move toward reimbursement for this 
critical and cost saving component of a comprehensive behavioral health 
system would allow for more ready access to the treatment and peer 
support services that individuals need when they are in crisis.
    Similarly, access to case management is essential for individuals 
facing substance abuse and behavioral health issues--particularly for 
those leaving incarceration or inpatient stays who are high risk and 
must receive wrap-around services that connect them immediately to 
needed medical and psychiatric assistance. These case management 
services have inconsistent reimbursement but there is significant 
medical literature linking those services to higher quality care and 
ultimately lowered cost. Many States have expanded their definitions of 
reimbursable, targeted care management to cover some aspects of these 
services, but the Federal Government could also explore reimbursement 
models via the Centers for Medicaid and Medicare.
    Focus on Prevention and Stigma Reduction. Additionally, more 
funding for prevention services is critical to stopping the cycle of 
addiction. Treatment and service intervention for individuals with 
identified need are often seen as top funding priorities; however, 
investing in prevention services and tackling substance upstream is 
just as important. Many local jurisdictions like Baltimore have 
launched public education campaigns to this effect, but there is much 
more education that must be done in order to encourage people with 
addiction into care and to disband stigmas that are leading many 
communities to avoid providing treatment altogether. Local 
jurisdictions are limited by funding constraints, but the Federal 
Government can push for the launch of a national campaign to reduce 
stigma and to increase awareness of opioid addiction. This national 
campaign will provide the spotlight this critical issue requires.

    Question 2. I am aware of the terrible toll that prescription 
opioid and heroin abuse can have on families, including children. When 
parents reach out to local governments for help with their opioid 
addiction, what extra actions need to be taken to ensure that their 
children do not fall through the cracks? Are there steps the Federal 
Government can take to assist in these efforts?
    Answer 2. As mentioned above, access to comprehensive treatment 
services and supports are crucial for any individual impacted by opioid 
misuse. Essential actions include the following:

     Case management support and parenting education. As 
described above, wraparound services for patients are essential--in the 
case of children and families, there must be protocols in place to 
ensure data-sharing and alignment between, for example, a case manager 
positioned within a behavioral health provider and case managers that 
have been assigned via the Department of Social Services or Child 
Protective Services. As with many government agencies, transparency 
between these entities is often limited. Federal incentives to ensure 
greater access to information, as well as grant funding to pilot 
innovative ways of partnering--similar to funding for diversion 
programs that bring together the criminal justice system and health 
system--are essential to ensuring this alignment.
     Generational education and counseling. Families facing 
addiction issues should receive ongoing education and support around 
the impact of addiction, early detection signs, and options for 
counseling and treatment. In Baltimore, our ``Bmore in Control'' 
program, as outlined above, is targeted at youth who may have 
experienced a parent or relative going through substance abuse and are 
looking for additional resources or simply a place to engage in dialog 
with others who have gone through similar experiences. Federal 
investment in increased counseling services for youth, as well as 
education and awareness programs like ``Bmore in Control'' can help 
break the all-too-frequent generational cycle of addiction by targeting 
specific interventions toward youth.
     Foster Care Reform. Finally, with increased opioid abuse 
leading to increased numbers of children ending up in the foster care 
system, it is imperative that we consider the overlap between the 
foster care system and substance abuse efforts. Federal funding to 
improve the quality of foster care services and coordination nationwide 
are essential to ensuring that no child falls through the cracks.
                            senator franken
    Question 1a. According to SAMHSA only 10 percent of people who need 
treatment for substance abuse received it. The health parity act of 
2008 and the ACA require mental health and substance abuse services to 
be covered to the same extent as physical health services. Yet, I have 
heard on numerous occasions that this is not the case. Furthermore, 
Medicaid currently prohibits the use of Federal funds for care provided 
to most patients in mental health and substance use disorder 
residential treatment facilities larger than 16 beds. This is known as 
the IMD exclusion.
    Why are so few people who are suffering from substance abuse 
disorders able to access treatment services and what interventions 
would help improve treatment rates?
    Answer 1a. The barriers to treatment are multi-pronged. In 
Baltimore City, we have identified the following hurdles--as well as 
proven solutions for addressing those hurdles, which the Federal 
Government can play a key role in supporting.
    Naloxone accessibility and cost. One core challenge we face at the 
community level is naloxone accessibility, which varies even within a 
single city jurisdiction. Naloxone is a generic medication that is part 
of the World Health Organization's list of essential medications, but 
pharmacies vary in their stocking methods and sometimes do not fulfill 
prescriptions for this life-saving antidote. Additionally, the price of 
naloxone has dramatically increased over the past 2 years--in Baltimore 
alone, the cost per dose of naloxone has quadrupled--meaning that we 
can only save a quarter of the lives we could have saved.
    This is particularly problematic for cities and counties that must 
purchase naloxone for use by paramedics, police officers, and other 
front-line workers. Manufacturers have claimed that this price increase 
is related to increased demand. However, it is unclear why the cost of 
a generic medication that is available for much lower costs in other 
countries will be suddenly so expensive. These challenges are not 
unique to Baltimore, and Congress can help overcome this obstacle by 
calling for investigation into the reason for the price increase. 
Additionally, the Federal Government should remove barriers that 
prohibit easy access to naloxone: for example, by making it available 
as an over the counter medication that is covered by both private and 
public insurance.
    Access to treatment. Regardless of jurisdiction, we need to ensure 
that there are sufficient high-quality treatment options available to 
those suffering from opioid addiction. There are several ways that the 
Federal Government can impact access to treatment:

     Federal funding could expand treatment on-demand including 
24/7 dedicated centers for substance addiction and mental health and 
proven intervention models such as LEAD and expand case management 
services for vulnerable individuals. These programs will help to ensure 
that those in need have a path to recovery.
     Congress can push for equitable insurance coverage for 
addiction services. Medicare pays for pain medications that can lead to 
addiction, yet many States do not cover medication-assisted treatment 
and other evidence-based interventions for addiction recovery. Congress 
can ensure that Medicaid, Medicare, and private payers cover on-demand 
treatment for acute care (such as sobering, urgent care, and 
residential services), as well as ongoing treatment and services like 
medication-assisted treatment and case management. These rates should 
also be equivalent to mental health and physical health care rates 
(which they are not currently, leading to a dearth of providers and 
inadequate care).
     Congress can remove barriers to prescribing Buprenorphine. 
Buprenorphine is a medication-assisted treatment option with a much 
lower chance of overdose than methadone. Importantly, it can be 
administered by a primary care provider rather than in a designated 
drug-treatment clinic. This helps to increase the accurate perception 
that substance use disorder is a medical condition. Unfortunately, at 
the moment, only medical doctors can prescribe buprenorphine, and a 
doctor can only provide Buprenorphine to a maximum of 100 patients. 
This barrier does not exist for any other medication, and significantly 
limits the ability of patients to access a life-saving treatment option 
and leaves many patients with methadone as their only option for 
medication-assisted treatment. Methadone requires administration in a 
designated treatment clinic, which are often a point of contention 
within the communities in which they operate due to the stigma 
associated with drug addiction. We strongly support current efforts 
underway at the Department of Health and Human Services to revise the 
limits on buprenorphine prescription in a given year, and urge further 
support of broadened access 8 to this proven treatment including by 
requesting Congress to consider broadening prescription authority of 
Buprenorphine to Nurse Practitioners and other providers.

    Crisis response. One of the biggest hurdles in the behavioral 
health system is the necessity of developing a full range of integrated 
crisis response services that divert people away from a criminal 
justice response and/or high cost inpatient services. The crisis 
response system serves as a major access point in the overall public 
behavioral health system. Because crises are defined by individuals and 
are also the point in time when individuals could be most willing to 
accept treatment for substance use disorder, having a 24/7 crisis 
response system is a critical component of ``treatment on demand''. 
However, the majority of crisis response services are not reimbursable 
by Medicaid. Federal action to move toward reimbursement for this 
critical and cost saving component of a comprehensive behavioral health 
system would allow for more ready access to the treatment and peer 
support services that individuals need when they are in crisis.
    Similarly, access to case management is essential for individuals 
facing substance abuse and behavioral health issues--particularly for 
those leaving incarceration or inpatient stays who are high-risk and 
must receive wrap-around services that connect them immediately to 
needed medical and psychiatric assistance. These case management 
services have inconsistent reimbursement but there is significant 
medical literature linking those services to higher quality care and 
ultimately lowered cost. Many States have expanded their definitions of 
reimbursable, targeted care management to cover some aspects of these 
services, but the Federal Government could also explore reimbursement 
models via the Centers for Medicaid and Medicare.

    Question 1b. How has the Medicaid IMD exclusion affected a 
patient's ability to access treatment for substance abuse?
    Answer 1b. The IMD exclusion is a hurdle for individuals in need of 
services. Residential substance use facilities are currently prohibited 
from receiving Medicaid reimbursement because of this exclusion. 
Although States can apply for a waiver, the process is lengthy and does 
not enable us to address the urgent numbers of people who are currently 
dying from overdose. In addition, the IMD waiver limits the number of 
mental health residential crisis beds and residential detox beds that 
are available for individuals in crisis, which again is a critical 
access point in any successful behavioral health system. If the 
exclusion were eliminated, grant funding that is currently used to 
purchase these types of service could be used for other services that 
individuals are in great need of, such as supportive housing.

    Question 1c. Do you feel that mental health and substance abuse 
parity is impacting patients' access to care? If so, how would you 
recommend we further ensure that a patient's mental health care is 
supported at rates equal to care for physical ailments?
    Answer 1c. Yes, we believe that parity is a major issue impacting 
patients' access to care. As discussed in previous answers, financial 
reimbursement for certain mental health services, including coverage of 
methadone treatment and behavioral health therapy, or services provided 
by all substance abuse treatment centers, regardless of whether they 
are residential or commercial, is key to ensuring that patients access 
the treatment that they need.

    Question 2. Medicaid does not pay for any treatment, including 
substance abuse and other mental health treatments, for individuals in 
public institutions. This includes jails and juvenile detention, and 
even applies to people who are awaiting trial and still presumed to be 
innocent. However, individuals with private insurance who remain in 
jail until trial can receive benefits, as can Medicaid beneficiaries 
who post bond. Medicaid's prohibition unfairly penalizes low-income 
individuals who cannot afford to post bond or pay for private coverage. 
This is especially problematic when it comes to mental illness and 
substance abuse because successful treatment requires continuity of 
care. When a person's health insurance coverage is disrupted, so is 
their access to consistent medical care. This lack of continuity can 
lead to serious health consequences for the individual and for the 
community.
    Baltimore has numerous programs underway to help individuals who 
suffer from mental illness connect to treatment after they encounter 
the criminal justice system. Do you have any programs to help ensure 
the continuation of medical care for Medicaid recipients as they await 
trial? What steps can the Federal Government take to minimize the 
disruptions in care for justice involved individuals?
    Answer 2. The Baltimore City Health Department concurs that 
diversion and treatment opportunities for individuals who have contact 
with the criminal justice system is highly important. Here in 
Baltimore, we have piloted a law enforcement-assisted diversion program 
in partnership with the Department of Justice and the Baltimore City 
police department, which establishes criteria for police officers to 
identify eligible users and take them to an intake facility that 
connects them to necessary services such as drug treatment, peer 
supports, and housing--rather than to central booking for arrest.
    We also utilize highly effective diversion effort such as Drug 
Treatment Courts and Mental Health Treatment Courts, which ensure that 
individuals facing substance abuse and behavioral health challenges are 
able to access necessary services. At the other end of the criminal 
justice pipeline, we are increasing our capability for case management 
services for every individual leaving jails and prisons. These 
individuals are at a highly vulnerable state, and must be connected to 
medical treatment, psychiatric and substance abuse treatments if 
appropriate, housing and employment support, and more. Our outreach 
workers already target a subset of this population; we need to expand 
capacity to every one of these individuals. Additionally, as mentioned 
above, we are deploying community health workers in order to reach 
people where they are in the community as well as provide a credible 
messenger. In deploying this tactic, we are also excited to bring jobs 
and opportunities to vulnerable individuals and neighborhoods that 
otherwise have limited employment opportunities.

    Question 3a. Current data has shown that the number of Medicaid-
covered babies born in Minnesota with neonatal abstinence syndrome has 
more than doubled over the past 4 years. Dr. Wen, in your testimony you 
describe the importance of universal drug screenings for individuals 
presenting in emergency rooms and primary care offices. In Minnesota, 
HealthPartners is similarly screening all pregnant women for substance 
abuse. This practice is showing significant improvements in health 
outcomes.
    What motivated providers in Baltimore to implement universal 
screening programs? How has it affected rates of opioid treatment 
across all populations?
    Answer 3a. We have implemented the Screening, Brief Intervention, 
and Referral to Treatment (SBIRT) approach, which provides universal 
screening of patients presenting to ERs and primary care offices. Three 
of our hospitals are early pioneers in SBIRT; we are looking to expand 
it to all hospitals and clinics in the city to ensure delivery of early 
intervention and treatment services for those with or at risk for 
substance use disorders. Our hospital providers were motivated by the 
effectiveness of having a unified approach to screening patients for 
behavioral health and substance abuse issues, given the following 
benefits: (1) effective, evaluated process for assessing potential 
misuse and ensuring that patients can be matched with the appropriate 
treatment services; (2) ability to share data across clinical settings, 
given the standardized screening tool; (3) participation in a city-wide 
convening of emergency room departments and other hospital leaders.
    While this is a relatively new intervention and we do not yet have 
quantitative data regarding the impact of this screening in Baltimore, 
studies have been conducted in several settings nationwide that 
demonstrate a range of 10-20 percent decrease in patients reporting 
opioid drug use 6 months after the intake is administered. These 
results also point to potential cost savings to the healthcare system: 
for example, a 2005 study found that the SBIRT process led to a $3 
reduction in healthcare costs for each $1 spent on the intervention.

    Question 3b. Dr. Wen, how would you design a national screening 
program aimed at reducing the rates of neonatal abstinence syndrome? 
What substances would you screen for and which locations within the 
continuum of care would you do this screening?
    Answer 3b. The American Academy of Pediatrics and the American 
Pediatrics Association have developed standard recommendations 
regarding screening infants for neonatal abstinence. These screens 
should be administered at any point within the care continuum in which 
a pregnant mom with prior history of drug abuse comes into contact with 
the healthcare system. Maternal factors to be taken into account when 
developing screening protocols include:

     History of drug use/abuse (licit or illicit) within the 
past year--including amphetamines, barbiturates, benzodiazepines, 
cocaine, marijuana, and opiates;
     Past history of narcotic use;
     No prenatal care or infrequent prenatal care (< 5 visits); 
and
     History of positive toxicology screens during prenatal 
care or during previous pregnancy.

    Screening protocols should also include a best practice around 
informing the mother that she and/or the infant will be tested, and any 
testing for criminal issues must require consent. Hospitals typically 
have standard legal standards in place for requests for release of any 
potentially incriminating information to legal authorities.
                             senator bennet
    Question 1. How can we ensure that patients who need to be treated 
for addiction can receive care while preventing diversion for opioid 
drug abuse?
    Answer 1. In Baltimore City, we have developed a comprehensive 
overdose strategy that is based on the philosophy that every 
interaction with a person with substance addiction must be treated as 
an entry point for intervention and treatment. These include:

     Crisis Response: In Baltimore, we have started a 24/7 
``crisis, information, and referral'' phone line that connects people 
in need to a variety of services including: immediate consultation with 
a social worker or addiction counselor; connection with outreach 
workers who provide emergency services and will visit people in crisis 
at homes; information about any question relating to mental health and 
substance addiction; and scheduling of treatment services and 
information. This line is not just for addiction but for mental health 
issues, since these issues in behavioral health are so closely related 
and there is a high degree of co-occurrence. Those who are seeking 
treatment for behavioral health should be able to easily access the 
services they need, at any time of day. This 24/7 line has been 
operational since October 2015; already, there are nearly 1,000 phone 
calls every week. It is being used not only by individuals seeking 
assistance, but by family members seeking resources and providers 
looking to connect their patients to treatment.
     No Wrong Door: We have secured $3.6 million in capital 
funds to build a ``stabilization center''--also known as a sobering 
center--for those in need of temporary service related to intoxication. 
This is the first step in our efforts to start a 24/7 ``Urgent Care'' 
for addiction and mental health disorders--a comprehensive, community-
based ``ER'' dedicated to patients presenting with substance abuse and 
mental health complaints. Just as a patient with a physical complaint 
can go into an ER any time of the day for treatment, a person suffering 
from addiction must be able to seek treatment on-demand. This center 
will enable patients to self-refer or be brought by families, police, 
or EMS--a ``no wrong door'' policy ensures that nobody would be turned 
away. The center would provide full capacity treatment in both 
intensive inpatient and low-intensity outpatient settings, and connect 
patients to case management and other necessary services such as 
housing and job training.
     Patient Tracking: We are developing a real-time treatment 
dashboard to obtain data on the number of people with substance use 
disorders, near-fatal and fatal overdoses, and capacity for treatment. 
This will enable us to map the availability of our inpatient and 
outpatient treatment slots and ensure that treatment availability meets 
the demand. The dashboard will be connected to our 24/7 line that will 
immediately connect people to the level of treatment that they 
require--on demand, at the time that they need it.
     Peer Recovery Specialists: We are expanding our capacity 
to treat overdose in the community by hiring community-based peer 
recovery specialists. These individuals will be recruited from the same 
neighborhoods as individuals with addiction, and will be trained as 
overdose interrupters who can administer overdose treatment and connect 
patients to treatment and other necessary services.
     SBIRT: We have implemented the Screening, Brief 
Intervention, and Referral to Treatment (SBIRT) approach, which 
provides universal screening of patients presenting to ERs and primary 
care offices. Three of our hospitals are early pioneers in SBIRT; we 
are looking to expand it to all hospitals and clinics in the city to 
ensure delivery of early intervention and treatment services for those 
with or at risk for substance use disorders.
     Case Management and Diversion: We are working to expand 
case management and diversion programs across the city so that those 
who need help get the medical treatment they need. In our city of 
620,000, 73,000 people are arrested each year. The majority of these 
arrests are due to drug offenses. Of the individuals in our jails and 
prisons, 8 out of 10 use illegal substances and 4 out of 10 have a 
diagnosed mental illness. Addiction and mental illness are diseases, 
and we should be providing medical treatment rather than incarcerating 
those who have an affliction. Baltimore already has highly effective 
diversion efforts such as Drug Treatment Courts and Mental Health 
Treatment Courts. We are looking to implement a Law Enforcement 
Assisted Diversion Program, a pilot model that has been adopted by a 
select group of cities, which establishes criteria for police officers 
to identify eligible users and take them to an intake facility that 
connects them to necessary services such as drug treatment, peer 
supports, and housing--rather than to central booking for arrest. 
Finally, we are increasing our capability for case management services 
for every individual leaving jails and prisons. These individuals are 
at a highly vulnerable state, and must be connected to medical 
treatment, psychiatric and substance abuse treatments if appropriate, 
housing and employment support, and more. Our outreach workers already 
target a subset of this population; we need to expand capacity to every 
one of these individuals. Additionally, as mentioned above, we are 
deploying community health workers in order to reach people where they 
are in the community as well as provide a credible messenger. In 
deploying this tactic, we are also excited to bring jobs and 
opportunities to vulnerable individuals and neighborhoods that 
otherwise have limited employment opportunities.

    Question 2. What suggestions would you have for strengthening 
Medication-Assisted Treatment? Is there a need to enhance psychosocial 
or behavioral components?
    Answer 2. In Baltimore, we are expanding and promoting medication-
assisted treatment, which is an evidence-based and highly effective 
method to help people with opioid addiction recover, through the use of 
best practices and standards throughout the city. This combines 
behavioral therapy with medication, such as methadone or buprenorphine, 
along with other support. Taking medication for opioid addiction is 
like taking medication to control heart disease or diabetes. When 
prescribed properly, medication does not create a new addiction, but 
rather manages a patient's addiction so that they can successfully 
achieve recovery.
    Baltimore has been at the leading edge of innovation for 
incorporating medication-assisted treatment, including providing 
medications in structured clinical settings through the Baltimore 
Buprenorphine Initiative. This year, we expanded access to 
buprenorphine treatment by offering services in low-barrier settings, 
such as recovery centers, emergency shelters, and mental health 
facilities. Providing access to buprenorphine services in these 
settings allows us to engage people who are more transient or unstably 
housed into much-needed treatment. There is absolutely a need to 
combine Medication-Assisted Treatment with attention to psychosocial 
and behavioral needs. As described above, this is where funding for and 
implementation of case management services and other innovative models 
is crucial.

    Question 3. You discussed removing the stigma associated with 
naloxone therapy to reverse an opioid drug overdose. Is there anything 
else we can do to remove the stigma associated with opioid abuse and 
increase access to care?
    Answer 3. Yes. In addition to treating patients, we must also 
change the dialog around substance use disorder. The Baltimore City 
Health Department is leading a citywide effort to educate the public 
and providers on the nature of substance addiction: that it is a 
disease, recovery is possible, and we all must play a role in 
preventing addiction and saving lives. Our efforts include the 
following:

     Community Education. We have been at the forefront of 
changing public perception of addiction so those in need are not 
ashamed to seek treatment. We have launched a public education campaign 
``DontDie.org'' to educate citizens that addiction is a chronic disease 
and to encourage individuals to seek treatment. This was launched with 
bus ads, billboard ads, a new website, and a targeted door-to-door 
outreach campaign in churches and with our neighborhood leaders. We 
have also launched a concerted effort to target prevention among our 
teens and youth entitled ``BMore in Control.'' We have established 
permanent prescription drug drop boxes at all nine of the city's police 
stations. This means that anyone can drop-off their unused, unwanted, 
or unnecessary prescription drugs--no questions asked. Drugs left in 
the home can end up in the wrong hands--spouses, elderly family 
members, or even our children. I have treated 2-year olds who were 
dying from opioid overdose, again underscoring that all of us can be at 
risk and must play a role.
     Clinician Education: We are targeting our educational 
efforts to physicians and other prescribers of opioid medications. 
Nationwide, over-prescribing and inconsistent monitoring of opioid pain 
medications is a major contributing factor to the overdose epidemic. 
According to the Centers for Disease Control, there were 259 million 
prescriptions written for opioids in 2014. That is enough for one 
opioid prescription for every adult American.
    Every day, people overdose or become addicted to their prescription 
opioids. To address this, I have sent ``best practice'' letters to 
every doctor in the city and will also do so for all dentists and 
pharmacists. The letter addressed the importance of the Prescription 
Drug Monitoring Program and judicious prescribing of opioids, including 
not using narcotics as the first line of medication for acute pain and 
emphasizing the risk of addiction and overdose with opioids. 
Importantly, this best practice requires co-prescribing of naloxone for 
any individual taking opioids or at risk for opioid overdose. Hospitals 
keep naloxone on hand if patients receive too much intravenous morphine 
or fentanyl. Patients must also receive a prescription for naloxone if 
they are to be discharged with opioid medications that can result in 
overdose. These best practices were developed through convening ER 
doctors, hospital CEOs, and other medical professionals in the city. To 
reach practicing doctors, we have been presenting at Grand Rounds, 
medical society conferences, and are also about to launch physician 
``detailing'', where we will employ teams of public health outreach 
workers and people in recovery to visit doctors to talk about best 
practices for opioid prescribing. We are working with providers to 
ensure best seven practices will be used when prescribing opioids and 
that we all play our part--as providers, patients, and family members--
to prevent addiction and overdose.

    Question 4. Based on your experience in addressing the occurrence 
of opioid abuse and overdose in Baltimore, what hurdles need to be 
addressed on State and local levels?
    Answer 4. Our approach to the opioid abuse epidemic in Baltimore 
City is evidence-based and comprehensive, and necessitates that we 
focus not only on what is achievable here in our city but also the 
multitude of local, State, and Federal-level factors that contribute to 
opioid use nationwide.
    Naloxone accessibility and cost. One core challenge we face at the 
community level is naloxone accessibility, which varies even within a 
single city jurisdiction. Naloxone is a generic medication that is part 
of the World Health Organization's list of essential medications, but 
pharmacies vary in their stocking methods and sometimes do not fulfill 
prescriptions for this life-saving antidote. Additionally, the price of 
naloxone has dramatically increased over the past 2 years--in Baltimore 
alone, the cost per dose of naloxone has quadrupled--meaning that we 
can only save a quarter of the lives we could have saved.
    This is particularly problematic for cities and counties that must 
purchase naloxone for use by paramedics, police officers, and other 
front-line workers. Manufacturers have claimed that this price increase 
is related to increased demand. However, it is unclear why the cost of 
a generic medication that is available for much lower costs in other 
countries will be suddenly so expensive. These challenges are not 
unique to Baltimore, and Congress can help overcome this obstacle by 
calling for investigation into the reason for the price increase. 
Additionally, the Federal Government should remove barriers that 
prohibit easy access to naloxone: for example, by making it available 
as an over the counter medication that is covered by both private and 
public insurance.
    Access to treatment. Regardless of jurisdiction, we need to ensure 
that there are sufficient high-quality treatment options available to 
those suffering from opioid addiction. There are several ways that the 
Federal Government can impact access to treatment:

     Federal funding could expand treatment on-demand including 
24/7 dedicated centers for substance addiction and mental health and 
proven intervention models such as LEAD and expand case management 
services for vulnerable individuals. These programs will help to ensure 
that those in need have a path to recovery.
     Congress can push for equitable insurance coverage for 
addiction services. Medicare pays for pain medications that can lead to 
addiction, yet many States do not cover medication-assisted treatment 
and other evidence-based interventions for addiction recovery. Congress 
can ensure that Medicaid, Medicare, and private payers cover on-demand 
treatment for acute care (such as sobering, urgent care, and 
residential services), as well as ongoing treatment and services like 
medication-assisted treatment and case management. These rates should 
also be equivalent to mental health and physical health care rates 
(which they are not currently, leading to a dearth of providers and 
inadequate care).
     Congress can remove barriers to prescribing Buprenorphine. 
Buprenorphine is a medication-assisted treatment option with a much 
lower chance of overdose than methadone. Importantly, it can be 
administered by a primary care provider rather than in a designated 
drug-treatment clinic. This helps to increase the accurate perception 
that substance use disorder is a medical condition. Unfortunately, at 
the moment, only medical doctors can prescribe buprenorphine, and a 
doctor can only provide Buprenorphine to a maximum of 100 patients. 
This barrier does not exist for any other medication, and significantly 
limits the ability of patients to access a life-saving treatment option 
and leaves many patients with methadone as their only option for 
medication-assisted treatment. Methadone requires administration in a 
designated treatment clinic, which are often a point of contention 
within the communities in which they operate due to the stigma 
associated with drug addiction. We strongly support current efforts 
underway at the Department of Health and Human Services to revise the 
limits on buprenorphine prescription in a given year, and urge further 
support of broadened access 8 to this proven treatment including by 
requesting Congress to consider broadening prescription authority of 
Buprenorphine to Nurse Practitioners and other providers.

    Crisis response. One of the biggest hurdles in the behavioral 
health system is the necessity of developing a full range of integrated 
crisis response services that divert people away from a criminal 
justice response and/or high cost inpatient services. The crisis 
response system serves as a major access point in the overall public 
behavioral health system. Because crises are defined by individuals and 
are also the point in time when individuals could be most willing to 
accept treatment for substance use disorder, having a 24/7 crisis 
response system is a critical component of ``treatment on demand''. 
However, the majority of crisis response services are not reimbursable 
by Medicaid. Federal action to move toward reimbursement for this 
critical and cost saving component of a comprehensive behavioral health 
system would allow for more ready access to the treatment and peer 
support services that individuals need when they are in crisis.
    Similarly, access to case management is essential for individuals 
facing substance abuse and behavioral health issues--particularly for 
those leaving incarceration or inpatient stays who are high risk and 
must receive wrap-around services that connect them immediately to 
needed medical and psychiatric assistance. These case management 
services have inconsistent reimbursement but there is significant 
medical literature linking those services to higher quality care and 
ultimately lowered cost. Many States have expanded their definitions of 
reimbursable, targeted care management to cover some aspects of these 
services, but the Federal Government could also explore reimbursement 
models via the Centers for Medicaid and Medicare.
    Focus on Prevention. Additionally, more funding for prevention 
services is critical to stopping the cycle of addiction. Treatment and 
service intervention for individuals with identified need are often 
seen as top funding priorities; however, investing in prevention 
services and tackling substance upstream is just as important. Many 
local jurisdictions like Baltimore have launched public education 
campaigns to this effect, but there is much more education that must be 
done in order to encourage people with addiction into care and to 
disband stigmas that are leading many communities to avoid providing 
treatment altogether. Local jurisdictions are limited by funding 
constraints, but the Federal Government can push for the launch of a 
national campaign to reduce stigma and to increase awareness of opioid 
addiction. This national campaign will provide the spotlight this 
critical issue requires.
                           senator whitehouse
    Question 1a. Along with a bipartisan group of Senators including 
Senators Portman, Klobuchar, and Ayotte, I introduced a bill earlier 
this year called the Comprehensive Addiction and Recovery Act (S. 524). 
The bill authorizes a series of grants to States and other eligible 
entities to promote an integrated approach--including prevention, 
treatment, law enforcement tools, and recovery support--to the 
substance abuse epidemic we are facing across the Nation. Among other 
things, the bill tries to increase screening for, and treatment of, co-
occurring mental health and substance use disorders in the juvenile and 
criminal justice systems and elsewhere.
    Do you support the objectives set forth in S. 524? How would 
enactment of S. 524 improve your organization's ability to help address 
the opioid abuse epidemic?
    Answer 1a. We strongly support the objectives set forth in S. 524. 
This bill would provide funding for States to prepare a comprehensive 
plan for and implement an integrated opioid abuse response initiative. 
We fully support this proposal but encourage you to consider making 
this grant available to local jurisdictions as many local health 
departments represent the boots on the ground in the fight against 
addiction and overdose.
    This bill would also support our efforts to train law enforcement 
personnel on naloxone by funding the creation of a formal opioid 
overdose prevention training program. As law enforcement personnel are 
often the first responders to a scene of an overdose, providing this 
training can save lives.
    We suggest that this grant opportunity be expanded to include 
funding for the procurement of naloxone. Over the last 2 years, the 
price of naloxone has dramatically increased. In Baltimore, the cost 
per dose has quadrupled. While manufacturers claim that this price 
increase is related to increased demand, it is unclear why the cost of 
a generic medication, that is available for much lower costs in other 
countries, is suddenly so expensive. We also encourage Congress to call 
for an investigation into the reason for the price increase. Providing 
funding to supply law enforcement agencies with naloxone will help 
ensure our first responders are able to save lives.
    We fully support the proposal to increase access to quality and 
effective on-demand treatment and provide long-term recovery support; 
but encourage that grants only be made available to evidence-based 
treatments that have proven to effectively treat drug addiction. In 
Baltimore, we are working to expand and promote evidence-based 
medication-assisted treatment. This combines behavioral therapy with 
medication, including methadone or buprenorphine, along with other 
support.
    Finally, we fully support the proposal to fund diversion programs 
so that those who need help get the medical treatment they need. 
Addiction and mental illness are diseases, and we should be providing 
medical treatment rather than incarcerating those who have an 
affliction. This bill would promote more programs to help break the 
cycle of addiction rather than perpetuate the cycle through arrest and 
release policies.

    Question 1b. What additional tools might you like to see at your 
disposal to address the overlap between substance abuse and mental 
health issues?
    In addition to the funding opportunities recommended in S. 524, we 
believe it is crucial for Federal funding to support cutting-edge, 
evidence-based approaches to combating substance abuse as well. Many of 
these services are not covered by Medicaid, Medicare, or other forms of 
insurance that are critical to addiction recovery, but Congress can 
provide funding to local jurisdictions and to States do not simply 
focus on the medical component of addiction but the broader 
psychosocial components. These include:

     New care delivery models. There is research on new 
treatment options such as starting buprenorphine from ERs, mobile 
buprenorphine induction, or telemedicine treatment that would be not 
eligible for existing reimbursement yet offer much promise. These are 
examples of delivery models that local and State agencies should have 
the option of providing grant funding for, with the option of being 
included in Medicaid formulary after sufficient time and evidence.
     Peer recovery specialists. In Baltimore, we are aiming to 
provide a peer recovery specialist for every individual who presents 
for an overdose or addiction-related condition to our ERs and other 
facilities. However, we are limited by the lack of funding for these 
individuals. There should be opportunities for expanded funding and 
reimbursement for services rendered by these trained community health 
workers; grant funding to local and State agencies can be one way to 
pursue this.
     Case management services. Individuals leaving 
incarceration or inpatient stays are at very high risk; they must 
receive wrap-around services that connect them immediately to needed 
medical and psychiatric assistance. These case management services have 
inconsistent reimbursement; innovative programs including with 
telemedicine and use of peer recovery specialists should be encouraged.
     Community resources for recovery. Recovery from addiction 
involves more than clinical treatment but also support and long-term 
care. Local and State agencies can also innovate with interventions 
such as recovery housing and reentry support; Federal funding can 
assist in these necessary steps.
                             senator warren
    Question 1a. Prescription Drug Monitoring Programs (PDMPs) hold 
tremendous power to help health care providers identify and treat 
patients who are addicted to or at risk of becoming addicted to 
opioids. However, PDMPs are only as good as the data stored in them. A 
2013 Department of Health and Human Services report on ``Prescription 
Drug Monitoring Program Interoperability and Standards,'' found that 
PDMPs remain significantly underutilized in many States and recommended 
that the Federal Government take a leadership role in making them more 
useful to providers.
    Many patients have similar names and birthdays, making it possible 
for patients' PDMP records to become inappropriately merged or to be 
incomplete. To what extent are these patient record mismatches a 
barrier to the utility of PDMPs?
    Answer 1a. While patient record mismatches can be a challenge, PDMP 
algorithms are built to be as conservative as possible due to the fact 
that many who suffer from opioid addiction are unable to provide 
standard contact information or other identifying information. As a 
result, PDMPs have been designed to prevent misidentification, and 
while this may result in duplicate records from time to time, it is a 
safe way to ensure that patients are not receiving inappropriate or 
wasteful amounts of prescription drugs.
    We support the use of PDMPs and believe that it is essential to 
make them as user friendly and time-saving for clinicians as possible. 
One way to address the issue of patient record mismatches is to develop 
a unique identifier for each patient--this is standard practice for 
patient health records and could be similarly applied here. In 
Maryland, for example, we utilize CRISP, a statewide health information 
exchange that enables the development of patient records across 
institutions and provides physicians and their teams with insights into 
the care and prescriptions that a patient is receiving across multiple 
clinical settings. CRISP has driven significant efficiencies in 
identifying and unifying care plans for complex patients, and we 
believe that similar adoption of best practices could yield similar 
advantages for PDMP utilization as well.

    Question 1b. How would the implementation of technical 
interoperability standards--including a standard system for matching 
the correct patient to the correct record--make it easier for PDMPs to 
integrate with electronic health record systems and increase the rate 
of PDMP utilization?
    Answer 1b. The ability to uniquely identify an individual across 
systems is critical to improving health outcomes. The practice of 
public health touches on many aspects of an individual's life, many of 
the system interactions which people experience are not clinical 
(housing, food, etc). While patient matching and identification 
programs exist, they are focused on the clinical operations of isolated 
health systems. State health information exchanges improve this picture 
by extending the unique identification across a region, however the 
ability to combine this data with data sets outside of the clinical 
context remains one of the biggest challenges facing public health 
practitioners. PDMPs focus on the dispensing of drugs to an individual, 
however we know this is only a part of that individual's story. Being 
able to link this use with hospital admissions, needle exchange 
interactions, residential treatment programs, and other social programs 
is equally important.
    Interoperability standards are the foundation for advancement 
across technology systems. This has played out for the Internet in 
general (with standards such as TCP/IP), and we are seeing a similar 
trend across clinical systems with the adoption of protocols such as 
HL7. While standards must be driven by groups of stakeholders within a 
sector, the government can play a critical role in convening these 
partners or providing the incentives to create such standards. 
Meaningful use has done more to advance interoperability of health data 
in a short-time than any effort previously. A similar incentive program 
should be developed for the interoperability of non-clinical systems. 
Such an initiative would bring stakeholders to the table for data 
exchange conversations which today are burdened with complex technical 
integrations, and facing legal challenges not well understood by the 
participants.
  Response by Robert Valuck, Ph.D., RPh, FNAP to Questions of Senator 
  Murkowski, Senator Casey, Senator Franken, Senator Bennet, Senator 
                     Whitehouse and Senator Warren
    Thank you Senators Murkowski, Casey, Franken, Bennet, Whitehouse 
and Warren for the opportunity to answer your additional, specific 
questions on this critically important issue for our Nation. My answers 
are provided below, and I remain available to you for further dialog or 
to provide additional information. I look forward to working together 
to find solutions to the epidemic of opioid abuse in America.
                           senator murkowski
    Question 1a. Dr. Valuck, Colorado is, similar to Alaska, though to 
a lesser extent, a rural State. Access to care is a huge problem in my 
State for every kind of patient, but it is especially bad for people 
searching for a treatment program. Anchorage, the largest city with a 
population of 300,000, only has 14 detox beds. Juneau, the second-
largest city with a population of around 30,000, has none. So you can 
probably guess what access is like out in the more rural parts of 
Alaska, like Bethel or Nome.
    What has Colorado done to specifically engage the rural parts of 
your State?
    Answer 1a. We have worked extremely hard to engage the rural parts 
of Colorado in our efforts to address the opioid epidemic and its 
widespread effects. The Colorado Consortium for Prescription Drug 
Abuse, founded in 2013 to implement the Colorado Plan to Reduce 
Prescription Drug Abuse, includes over 300 members from across our 
State and serves as a backbone for collaboration, communication, and 
collective action. We have worked with coalitions in several rural 
areas of the State: the San Luis Valley (through a multi-county 
collaboration coordinated by the Area Health Education Center, or 
AHEC); northeast Colorado (through a collaboration coordinated by the 
North Colorado Health Alliance); and the Western slope (through a 
collaboration coordinated by Rocky Mountain Health Plans, the Mesa 
County Medical Society, and local providers). These coalitions have 
developed focused, regionally and culturally sensitive approaches to 
the problem, engaging community leaders, health care providers, law 
enforcement, public health agencies, treatment providers, and patients 
and families to determine the most desirable and feasible approaches 
that can be implemented in their respective locations. The Consortium, 
and the major State agencies in Colorado (public health, behavioral 
health, regulatory, and law enforcement) are working to support these 
rural coalitions, share best practices, facilitate dialog, and connect 
local and regional efforts with statewide efforts to achieve maximum 
impact. Moving forward, a State block grant from SAMHSA (administered 
by the Office of Behavioral Health, in the Department of Human 
Services) is being used to extend the reach of the consortium and its 
key outreach and prevention messaging (on safe use, safe storage, and 
safe disposal) to youth and young adults, through a 5-year 
collaboration with Rise Above Colorado. The grant will allow seven high 
risk communities to develop and implement local, youth-directed 
prevention programs using a positive youth development approach. Our 
goal is to reach and involve all of Colorado, both urban, suburban and 
rural; at all levels (local, county, and regional), to coordinate and 
leverage our efforts.

    Question 1b. Has Colorado leveraged Federal funds to provide detox 
or post-detox residential treatment for people dealing with addiction, 
or have you relied entirely on State funds?
    Answer 1b. Colorado does use Federal, State and local funds to 
support community-based, clinically managed residential withdrawal 
management (detox) services. Both Medicaid funds, and the Substance 
Abuse and Mental Health Services Administration (SAMHSA) Substance 
Abuse Prevention and Treatment (SAPT) Block Grant support this type of 
care.
    Colorado also supports residential treatment for substance use 
disorders using Federal SAMHSA SAPT Block Grant funds. Additionally, 
the State Medicaid program only includes residential treatment for 
substance use disorders for pregnant women. That treatment may continue 
up to 12 months postpartum, through a 1915B waiver. The postpartum 
services are only supported when the woman initiates treatment while 
pregnant.
    It should be noted that for withdrawal management, many in opiate 
withdrawal may require a higher level of care than is typically 
available and that does not get direct Federal funding.
                             senator casey
    Question 1. What kind of economic incentives do you feel are 
necessary for pharmacies, clinics and other organizations to become 
reverse distributors?
    Answer 1. At this time, there is no direct economic incentive for 
pharmacies, clinics, or other organizations to become reverse 
distributors. The costs of collection, storage, and ultimately disposal 
would be borne by these organizations, and such costs are substantial 
(and likely prohibitive, thus discouraging participation). Some form of 
economic model will be required to make reverse distribution a viable 
solution for safe disposal of opioids and other prescription drugs. 
Various models are being suggested and tested across the United States, 
ranging from requiring pharmaceutical manufacturers to fund disposal 
programs; to consideration of per-
prescription fees for disposal of unused medications (akin to hazardous 
materials disposal fees for used tires, motor oil, and paint); to 
legislative (general fund) funding of disposal programs. The Colorado 
legislature has provided 1 year of funding for a statewide pilot 
disposal program, but the long term viability of the program or the 
funding is unknown and cannot be guaranteed. Federal solutions are also 
possible, ranging from ongoing funding for the DEA National Takeback 
Initiative; to creating, providing funding for, or coordinating a 
national collection program for reverse distributors. Moving forward, 
we are paying close attention to efforts across the country to 
determine which are viable, feasible, and sustainable and could be 
considered for implementation in Colorado.
                            senator franken
    Question 1a. According to SAMHSA only 10 percent of people who need 
treatment for substance abuse received it. The health parity act of 
2008 and the ACA require mental health and substance abuse services to 
be covered to the same extent as physical health services. Yet, I have 
heard on numerous occasions that this is not the case. Furthermore, 
Medicaid currently prohibits the use of Federal funds for care provided 
to most patients in mental health and substance use disorder 
residential treatment facilities larger than 16 beds. This is known as 
the IMD exclusion.
    Why are so few people who are suffering from substance abuse 
disorders able to access treatment services and what interventions 
would help improve treatment rates?
    Answer 1a. The ``treatment gap'' that you mention is a terrible 
problem, resulting in countless Americans being unable to access 
treatment services, even when they are fully aware and ready and 
willing to enter treatment. Oftentimes, the long wait for treatment 
access leads to further abuse, overdose, and death. Barriers to 
treatment access are many: lack of available treatment facilities, 
programs, and providers; lack of insurance coverage for treatment; 
stigma and shame associated with seeking treatment; lack of awareness 
of available treatment options or methods for accessing treatment or 
obtaining referral to treatment; lack of parity in coverage for 
substance abuse services; and uneven distribution of services in many 
areas. Increases in all of these areas will be required to narrow the 
treatment gap and provide all Americans who need it, to have access to 
substance abuse treatment in their communities.

    Question 1b. How has the Medicaid IMD exclusion affected a 
patient's ability to access treatment for substance abuse?
    Answer 1b. The Medicaid IMD exclusion is one example of coverage-
related barriers to access to treatment for substance abuse. Such 
exclusions limit the availability of treatment options, and make it 
more difficult for Medicaid patients to obtain such services. This is 
particularly troubling, given the data that show Medicaid patients have 
a disproportionately high rate of opioid overdose compared with the 
general population.

    Question 1c. Do you feel that mental health and substance abuse 
parity is impacting patients' access to care? If so, how would you 
recommend we further ensure that a patient's mental health care is 
supported at rates equal to care for physical ailments?
    Answer 1c. Yes, I believe that mental health and substance abuse 
parity, or the lack thereof, is impacting patients' access to care. I 
recommend and support any efforts to clearly define, require, and 
enforce the application of parity laws. Coverage must be adequate; must 
comprise physical health, mental health, and substance abuse services; 
and must be enforced to assure compliance with laws that mandate it.
                             senator bennet
    Question 1. How can we ensure that patients who need to be treated 
for addiction can receive care while preventing diversion for opioid 
drug abuse?
    Answer 1. We believe that the key to ensuring access to opioids for 
patients with legitimate medical need (for the treatment of either 
acute or chronic pain, or addiction) while preventing misuse, abuse, 
and diversion is a balanced approach focusing on several key areas 
simultaneously: public awareness, provider education, increased use of 
prescription drug monitoring programs, safe storage, safe disposal 
programs, improved treatment systems, increased access to naloxone, and 
improved data systems, all working in a coordinated, collaborative, and 
multidisciplinary manner. We stress and believe in education and in the 
creation of evidence-based guidelines and tools for providers and 
patients to safely use opioids when medically indicated and prescribed, 
giving providers the ability to best treat their patients.

    Question 2. What suggestions would you have for strengthening 
Medication-
Assisted Treatment? Is there a need to enhance psychosocial or 
behavioral components?
    Answer 2. We support all efforts to expand access to Medication 
Assisted Treatment (MAT), including additional provider education and 
training on MAT; expansion of buprenorphine waiver limits; funding for 
additional treatment facilities, programs, and providers; improved 
mechanisms for referral to MAT treatment providers; and insurance 
reform to assure coverage of MAT for persons who need it. We believe 
that there is indeed a need to enhance the psychosocial and behavioral 
components of addiction treatment programs, and that physicians 
(particularly those specializing in addiction medicine) are best 
equipped to determine the most effective, safe, and evidence-based 
approach to addiction treatment for each of their patients, knowing 
that one approach is not likely to succeed for all patients.

    Question 3. Dr. Valuck, in your testimony, you note that over a 
quarter of a million Coloradans have misused prescription drugs. Due to 
the good work in Colorado, you and others have been able to see a 20 
percent reduction in this abuse. How can the Federal Government be a 
partner or get out of the way of the hard work that needs to be done?
    Answer 3. We believe that the Federal Government can, and should, 
partner with States to help implement programs that meet the needs 
defined in each State (which in some ways are similar, but in many ways 
are unique and require local or regional efforts to assure success). 
Agencies of the Federal Government should use their statutory authority 
and resources to address specific aspects of the opioid epidemic: FDA 
could move naloxone to ``over the counter'' status; DEA could continue 
to host National Takeback Initiatives or create an ongoing, permanent 
infrastructure for reverse distribution and ultimately safe destruction 
of unused opioids; CDC could assist with improving data systems and 
data sharing between PDMP programs, State health departments, and other 
agencies to help better understand, measure, and track the epidemic; 
HHS could increase efforts to expand access to MAT and increase the 
number of providers who are certified to provide MAT; and NIH could 
fund additional studies on everything from evidence-based treatments 
for addiction, to new classes of medications for treating pain, to 
evaluations of which prevention, intervention, or treatment strategies 
are most effective for reducing opioid overdose deaths. The Federal 
Government and its agencies should support and work with States to help 
them address this problem in a coordinated way.

    Question 4. Dr. Valuck, you discussed the dramatic increase in 
heroin and prescription opioid abuse admissions, yet the lack of 
existing treatment options available. What should Congress think about 
when trying to reduce the rates of use of both heroin and prescription 
opioids?
    Answer 4. We believe that efforts should be made to strike a 
balance--ensuring access to opioids for patients with legitimate 
medical need (for the treatment of either acute or chronic pain, or 
addiction) while preventing misuse, abuse, and diversion. Several key 
areas should be addressed simultaneously: public awareness, provider 
education, increased use of prescription drug monitoring programs, safe 
storage, safe disposal programs, improved treatment systems, increased 
access to naloxone, and improved data systems, all working in a 
coordinated, collaborative, and multidisciplinary manner. The opioid 
epidemic is a problem of massive scope, multifactorial causes, and 
staggering consequences. It requires us to address it in every way that 
we can, simultaneously, and will not be solved quickly or easily. The 
opioid epidemic is one of the defining public health crises of our 
generation.

    Question 5. You described several aspects of Colorado's plan to 
reduce prescription drug abuse including public awareness, patient 
engagement, strengthening the Prescription Drug Monitoring Program, and 
others. Are there certain components most important in achieving your 
goal of reducing non-medical use of prescription medications to 3.5 
percent?
    Answer 5. We believe that each of the components of our plan to 
reduce prescription drug abuse is critically important, and that the 
effort cannot succeed without continued emphasis on each and every one. 
The opioid epidemic has many causes, and many potential avenues for 
impact, and we believe that every available avenue should be pursued to 
address it. We are currently identifying both ``key performance 
indicators'' and ``outcome indicators'' to measure the scope and 
dimensions of the opioid epidemic, as well as the impact of our 
strategic planning (work group) domains on those indicators. Moving 
forward, we aim to determine which components of our approach work, how 
well they work, and how to most effectively address aspects of the 
epidemic in the coming years. We are moving to a clearly specified, 
data-driven approach with measurable goals and targets for our 
prevention work. The stakes are too high to move forward without 
measuring our efforts, to assure that we are as effective as we can be, 
given our limited resources.

    Question 6. Based on your experience in Colorado in seeing the 
implementation of that Policy for Prescribing and Dispensing Opioids, 
do you have concerns that CDC guidelines on opioid prescribing for 
chronic care pain in adults treated in the primary care setting will 
inappropriately limit patients' access to opioid medications?
    Answer 6. We are very fortunate to have experienced the creation of 
a very collaborative, innovative Policy for Prescribing and Dispensing 
Opioids by our State's health professions licensing boards. The policy 
is evidence-based, and was developed with the input of key 
stakeholders, to assure relevance to practitioners and patients in 
Colorado. The new (draft) CDC guidelines, while not yet finalized (at 
the time of this writing), may or may not serve to limit patients' 
access to opioid medications for legitimate medical need; we are paying 
close attention to the CDC guideline development process and will 
review the final guidelines when they are released.
                           senator whitehouse
    Question 1a. Along with a bipartisan group of Senators including 
Senators Portman, Klobuchar, and Ayotte, I introduced a bill earlier 
this year called the Comprehensive Addiction and Recovery Act (S. 524). 
The bill authorizes a series of grants to States and other eligible 
entities to promote an integrated approach--including prevention, 
treatment, law enforcement tools, and recovery support--to the 
substance abuse epidemic we are facing across the Nation. Among other 
things, the bill tries to increase screening for, and treatment of, co-
occurring mental health and substance use disorders in the juvenile and 
criminal justice systems and elsewhere.
    Do you support the objectives set forth in S. 524? How would 
enactment of S. 524 improve your organization's ability to help address 
the opioid abuse epidemic?
    Answer 1a. Yes, we believe that enactment of S. 524 would improve 
our ability to help address the opioid epidemic. Grant funding to 
States, to promote integrated approaches to the substance abuse 
epidemic, would be very useful to us. Such funding could help sustain 
our collaborative ``Consortium model'', which has proven to be an 
effective vehicle for organizing an effective network of systems and 
programs across Colorado. Further funding for prevention, screening and 
treatment of co-occurring mental health and substance use disorders in 
the juvenile and criminal justice systems would help stem the tide of 
addiction and reduce the number of persons who nonmedically use 
opioids, many of whom go on to become addicted and experience negative 
outcomes. Prevention of addiction is, and must be, the long term goal, 
and we support efforts to increase funding for integrated approaches to 
prevention.

    Question 1b. What additional tools might you like to see at your 
disposal to address the overlap between substance abuse and mental 
health issues?
    Answer 1b. We would like to see improved coverage (both in terms of 
scope and parity); improved access to treatment resources (additional 
facilities, programs, and providers); improved education of providers 
and patients; improved models of health care delivery that integrate 
mental health and substance abuse services with physical health 
services; and improved methods for screening, brief intervention, and 
referral to treatment, so that patients' specific condition(s) can be 
better identified, earlier, and referrals to appropriate services can 
be made, thus increasing the chances for successful treatment and 
lowering the chances for bad outcomes.
                             senator warren
    Question 1a. Prescription Drug Monitoring Programs (PDMPs) hold 
tremendous power to help health care providers identify and treat 
patients who are addicted to or at risk of becoming addicted to 
opioids. However, PDMPs are only as good as the data stored in them. A 
2013 Department of Health and Human Services report on ``Prescription 
Drug Monitoring Program Interoperability and Standards,'' found that 
PDMPs remain significantly underutilized in many States and recommended 
that the Federal Government take a leadership role in making them more 
useful to providers.
    Many patients have similar names and birthdays, making it possible 
for patients' PDMP records to become inappropriately merged or to be 
incomplete. To what extent are these patient record mismatches a 
barrier to the utility of PDMPs?
    Answer 1a. Patient record mismatches are one of several technical/
system problems that reduce the utility of PDMPs. Some States (not 
Colorado) require patients to show a State-issued identification card 
(driver's license, State-issued ID card, etc.) with a unique 
identification number, thus reducing the likelihood of patient record 
mismatches (or the use of aliases or false or fabricated name or 
address information). Other technical/system problems include multiple 
system sign-ons (i.e., PDMP users must log in separately to multiple 
systems in the course of their work, which makes checking the PDMP more 
time consuming and difficult); complex navigation; multiple 
attestations, password changes, and verifications; and in some States, 
data that are not uploaded frequently enough by pharmacies (per State 
law) and result in ``gaps'' in PDMP information (coverage). Each of 
these problems are barriers to PDMP utility and use.

    Question 1b. How would the implementation of technical 
interoperability standards--including a standard system for matching 
the correct patient to the correct record--make it easier for PDMPs to 
integrate with electronic health record systems and increase the rate 
of PDMP utilization?
    Answer 1b. We believe that the implementation of technical 
interoperability standards would indeed make it easier for PDMPs to 
integrate with electronic health record systems and increase the rate 
of PDMP utilization. ``Single sign on'' systems, record linkage 
systems, clinical decision support systems, patient monitoring/tracking 
systems, etc., could all be more easily deployed if technical 
interoperability standards were implemented. PDMP data are extremely 
valuable, and any efforts to make the data more easily accessible, 
while maintaining strict data privacy and security protections, would 
increase PDMP utilization and in turn, reduce the rate of doctor 
shopping and pharmacy shopping--one key dimension of the opioid 
epidemic.

    [Whereupon, at 11:48 a.m., the hearing was adjourned.]

                                   [all]