[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
__________
Printed for the use of the Committee on Health, Education, Labor, and
Pensions
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Available via the World Wide Web: http://www.gpo.gov/fdsys/
U.S. GOVERNMENT PUBLISHING OFFICE
97-955 PDF WASHINGTON : 2018
----------------------------------------------------------------------------------------
For sale by the Superintendent of Documents, U.S. Government Publishing Office,
http://bookstore.gpo.gov. For more information, contact the GPO Customer Contact Center,
U.S. Government Publishing Office. Phone 202-512-1800, or 866-512-1800 (toll-free).
E-mail, [email protected].
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]