[House Hearing, 115 Congress]
[From the U.S. Government Publishing Office]
A SUSTAINABLE SOLUTION TO THE EVOLVING OPIOID CRISIS: REVITALIZING THE
OFFICE OF NATIONAL DRUG CONTROL POLICY
=======================================================================
HEARING
BEFORE THE
COMMITTEE ON OVERSIGHT
AND GOVERNMENT REFORM
HOUSE OF REPRESENTATIVES
ONE HUNDRED FIFTEENTH CONGRESS
SECOND SESSION
__________
MAY 17, 2018
__________
Serial No. 115-82
__________
Printed for the use of the Committee on Oversight and Government Reform
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Available via the World Wide Web: http://www.fdsys.gov
http://oversight.house.gov
______
U.S. GOVERNMENT PUBLISHING OFFICE
31-121 PDF WASHINGTON : 2018
Committee on Oversight and Government Reform
Trey Gowdy, South Carolina, Chairman
John J. Duncan, Jr., Tennessee Elijah E. Cummings, Maryland,
Darrell E. Issa, California Ranking Minority Member
Jim Jordan, Ohio Carolyn B. Maloney, New York
Mark Sanford, South Carolina Eleanor Holmes Norton, District of
Justin Amash, Michigan Columbia
Paul A. Gosar, Arizona Wm. Lacy Clay, Missouri
Scott DesJarlais, Tennessee Stephen F. Lynch, Massachusetts
Virginia Foxx, North Carolina Jim Cooper, Tennessee
Thomas Massie, Kentucky Gerald E. Connolly, Virginia
Mark Meadows, North Carolina Robin L. Kelly, Illinois
Ron DeSantis, Florida Brenda L. Lawrence, Michigan
Dennis A. Ross, Florida Bonnie Watson Coleman, New Jersey
Mark Walker, North Carolina Raja Krishnamoorthi, Illinois
Rod Blum, Iowa Jamie Raskin, Maryland
Jody B. Hice, Georgia Jimmy Gomez, Maryland
Steve Russell, Oklahoma Peter Welch, Vermont
Glenn Grothman, Wisconsin Matt Cartwright, Pennsylvania
Will Hurd, Texas Mark DeSaulnier, California
Gary J. Palmer, Alabama Stacey E. Plaskett, Virgin Islands
James Comer, Kentucky John P. Sarbanes, Maryland
Paul Mitchell, Michigan
Greg Gianforte, Montana
Sheria Clarke, Staff Director
William McKenna, General Counsel
Sarah Vance, Health Care, Benefits, and Administrative Rules
Subcommittee Staff Director
Michael Koren, Professional Staff Member
Sharon Casey, Deputy Chief Clerk
David Rapallo, Minority Staff Director
C O N T E N T S
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Page
Hearing held on May 17, 2018..................................... 1
WITNESSES
Panel I
The Honorable John Cornyn, Senator from Texas and Senate Majority
Whip
Oral Statement............................................... 1
Panel II
Anand Parekh, MD, MPH, Chief Medical Advisor, Bipartisan Policy
Center
Oral Statement............................................... 8
Written Statement............................................ 10
Rahul Gupta, MD, MPH, MBA, FACP, Commissioner and State Health
Officer, Department of Health and Human Resources' Bureau for
Public Health, State of West Virginia
Oral Statement............................................... 14
Written Statement............................................ 16
Mr. Thomas Carr, Executive Director, Washington/Baltimore, High
Intensity Drug Trafficking Areas Program
Oral Statement............................................... 23
Written Statement............................................ 25
Ms. Gretta Goodwin, Director, Homeland Security and Justice, U.S.
Government Accountability Office
Oral Statement............................................... 31
Written Statement............................................ 33
APPENDIX
Representative Gerald E. Connolly Statement...................... 68
Response from Dr. Parekh, Bipartisan Policy Center, to Questions
for the Record................................................. 70
Response from Dr. Gupta, Bureau for Public Health West Virginia,
to Questions for the Record.................................... 72
A SUSTAINABLE SOLUTION TO THE EVOLVING OPIOID CRISIS: REVITALIZING THE
OFFICE OF NATIONAL DRUG CONTROL POLICY
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Thursday, May 17, 2018
House of Representatives,
Committee on Oversight and Government Reform,
Washington, D.C.
The committee met, pursuant to call, at 11:10 a.m., in Room
2154, Rayburn House Office Building, Hon. Trey Gowdy [chairman
of the committee] presiding.
Present: Representatives Gowdy, Sanford, Amash, DesJarlais,
Meadows, DeSantis, Ross, Walker, Blum, Hice, Grothman, Hurd,
Palmer, Comer, Cummings, Maloney, Norton, Lynch, Connolly,
Kelly, Krishnamoorthi, Welch, and DeSaulnier.
Chairman Gowdy. The Committee on Oversight and Government
Reform will come to order. Without objection, the presiding
member is authorized to declare a recess at any time.
Senator Cornyn, we are thrilled to have you. We realize
that there are votes that have been called in the Senate. So my
colleague from Maryland has graciously agreed to allow you to
make your opening first, and then we will allow you to go vote.
With that, you are recognized.
WITNESS STATEMENTS
PANEL I
STATEMENT OF THE HON. JOHN CORNYN
Senator Cornyn. Thank you Chairman Gowdy and Ranking Member
Cummings. I appreciate your courtesy and the opportunity to be
here today to address America's drug addiction crisis.
From 1999 to 2016, more than 350,000 Americans have died
from an overdose involving opioids, more people than in the
current population of the city in St. Louis. This epidemic is
hitting every community in every State, with more than 2,800
deaths in my home State of Texas in 2016.
But, of course, this didn't happen overnight. The Centers
for Disease Control and Prevention has outlined the rise of the
opioid overdose deaths in three distinct waves.
The first began in 1999 with increasing overdose deaths
attributed to prescription opioids. Then, in 2010, we saw a
rapid increase in overdose deaths involving heroin, which is
cheaper than diverted prescription opioids.
The third wave began in 2013 with significant increases in
overdose deaths involving synthetic opioids like illicitly
manufactured fentanyl. Of the more than 64,000 overdose deaths
in 2016, more than half were the result of heroin and synthetic
opioids, not prescription drugs.
What is clear is that addressing only prescription opioids
will not remedy this crisis. We must also halt the flow of
illicit drugs like heroin and fentanyl, including through
increased detection and intervention efforts at America's
borders and ports of entry.
Transnational criminal organizations and drug cartels will
stop at nothing to exploit Americans who are addicted to these
narcotics that are tearing apart our families and our
communities. And sadly, demand for the illicit drugs being sold
by these criminal organizations has only increased as we have
stepped up efforts to limit prescription opioid diversion.
Now more than ever, we need to carry out a comprehensive
and coordinated strategy across all levels of government to
address both the supply and the demand for illegal narcotics in
the United States.
That is why I am pleased to have worked with Senator Dianne
Feinstein to introduce the Substance Abuse Prevention Act of
2018 of the Senate. I hope you all will take a look at that.
Our bill strengthens and reauthorizes the Office of
National Drug Control Policy, which oversees all executive
branch efforts on narcotics control, implements a national drug
control strategy, and strengthens and complements State and
local antidrug activities.
This includes the High Intensity Drug Trafficking Area
program, which provides resources for Federal, State, and local
law enforcement task forces operating in our most critical drug
trafficking regions.
The bill also improves the program by targeting funds for
the implementation of a coordinated drug overdose response
strategy. It reauthorizes the Drug-Free Communities Program,
one of our most important programs for preventing substance
abuse and reducing demand for illicit narcotics at the
community level.
The Drug-Free Communities Program has been a central
bipartisan component of our Nation's demand reduction strategy
since its passage in 1998, because it recognizes that the drug
issue must be dealt with in every hometown in America.
Solving our drug addiction crisis requires more than just
law enforcement solutions. Families and communities must work
together to implement evidence-based approaches that prevent
drug addiction.
This is exactly the mission being carried out by Drug-Free
Communities Coalition partners, and their efforts are critical
to solving the drug abuse crisis.
And while we hope to prevent substance abuse from becoming
a criminal matter, there is no avoiding the fact that our
courts will always have a role to play in addressing drug
addiction challenges.
That is why this legislation would also reauthorize the
Department of Justice's Drug Court Program, which helps provide
judicial and law enforcement officials on the front lines with
the tools and the resources they need to help criminal
defendants seek treatment and rehabilitation instead of
repeating the tragic cycle of addiction and incarceration
without an opportunity to break that cycle.
Finally, the Substance Abuse Prevention Act also builds on
the achievements of the Comprehensive Addiction and Recovery
Act of 2016, known as CARA, to help families in substance abuse
challenges by providing resources for sobriety, treatment, and
recovery teams that pair social workers and peer mentors with
these families.
This legislation that I have described here is supported by
a broad coalition of 102 organizations, including the Community
Anti-Drug Coalitions of America, the Addiction Policy Forum,
the National Association for Children of Addiction, the
National Council for Behavioral Health, and the Fraternal Order
of Police.
Mr. Chairman, I know that you will soon introduce
legislation that would also reauthorize and strengthen the
ONDCP to address many of the issues that I have talked about
today. I look forward to working with you and your committee as
these bills move forward in our respective bodies so that we
can be sure that the Federal Government is doing everything in
our power to respond to this grave challenge facing our Nation.
I hope this committee and Members on both sides will
continue their efforts to find consensus solutions to our
substance abuse crisis. Saving our children, our families, and
our communities from drug addiction is a humanitarian issue,
not a partisan issue.
Mr. Chairman, thank you for allowing me to provide these
comments and for your many courtesies today.
Chairman Gowdy. Senator Cornyn, I know I speak on behalf of
all of the members on both sides of the aisle when we thank you
for your career in public service, in the justice system, in
law enforcement, and most recently, the United States Senate,
and for your leadership on this very important issue. And we
have benefited from your opening statement, and we thank you.
Senator Cornyn. Thank you, Mr. Chairman. I appreciate the
visa that allows me to visit the House side. And I will return
it promptly.
Chair Gowdy. You are welcome any time. Yes, sir.
We will briefly stand in recess while the second panel
assembles. And then Mr. Cummings and I will make our opening
statements.
[Recess.]
Chairman Gowdy. We welcome our second panel of witnesses.
Mr. Cummings and I will make our opening statements, then we'll
recognize you for your opening statements.
Our country is in an opioid crisis, and it's getting worse.
Statistics can be helpful because statistics help us quantify
and provide scope and scale. But statistics are what usually
happen to other people.
What paints the most vivid image of this crisis are those
who have lost children to overdose, those who are now and will
forever be in the throes of addiction, and those whose lives
have been ended, upended, and are in fear of retreat back
toward addiction.
The increasing reality is more and more as our fellow
Americans have come face to face with this crisis within their
own families, to say nothing of within their own communities
and the broader American family.
Each year over 64,000 Americans die from a drug overdose.
That's more than the number of Americans killed in the entirety
of the Vietnam war, a war which has consumed parts of the
American consciousness for over half a century.
And while consensus exists on the depth of this challenge
and the need to confront it in an apolitical way, the problem
is worsening as more potent drugs emerge and the online market
for illicit distribution expands.
Our country is in desperate need of a central coordinated
response. The issue knows no geographic boundary, is no
respecter of State lines, which means we need a coordinated
governmental response at the national level.
So 30 years ago, Congress created the Office of National
Drug Control Policy. This office is designed to play a central
role in coordinating the Nation's drug control policy and
programs. National drug control efforts are spread across 16
departments and agencies implementing programs and operations
throughout the U.S.
So a central coordinating body is essential to ensuring
effective evidence-based drug control programs. Drug control
efforts should be synchronized and targeted at achieving
specific strategic goals.
While the ONDCP continues to receive annual appropriations
from Congress, it nevertheless operates under an expired
authorization. Reauthorizing ONDCP with revamped and enhanced
authorities will improve coordination and effectiveness of
Federal agencies and their diverse drug control efforts.
ONDCP is also tasked with administering two grant programs,
HIDTA and the Drug-Free Communities. ONDCP is uniquely
positioned to administer these programs in a way that gives
those working at the State and local level a prominent seat at
the table.
As Congress appropriates increasing levels of funding, the
need for a national coordinating office is more important than
ever. And to be sure, our Nation's drug crisis will not be
curtailed merely by appropriating money. The money must be
spent in an effective way rooted in evidence, experience, and
expertise.
Last week our committee shared a discussion draft of
reauthorization text for the ONDCP. The committee has held
hearings and roundtable discussions to better inform our
reauthorization efforts. And through the posting of our draft
text online we've received constructive feedback from the
general public.
Today, we want to hear from partners about the importance
of reauthorizing ONDCP. By ensuring a synchronized national
effort we're better positioned to achieve our common goal of
ending this devastating crisis.
This week is the week we set aside each year in Congress to
honor law enforcement. So I want to end it by honoring someone
in law enforcement, an old narcotics officer by the name of
Kevin Simmers.
Kevin dedicated his career to the interdiction and
detection and apprehension of drug dealers. He wanted to do his
part to keep his community free from the scourges of addiction
and trafficking. He felt like he was doing the Lord's work.
But Kevin was not just a law enforcement officer. He was
also a father to a beautiful daughter named Brooke. Well, we
know addiction is no respecter of people, not even of law
enforcement officers who dedicate their lives to keeping drugs
away from other people's children. No one is immune.
So when Kevin's daughter Brooke developed an addiction, he
did everything a father could do. He tried treatment, he tried
unconditional love, he tried tough love. He tried treatment
again. Even tried jail.
You can imagine how hard it would be for a father to leave
his daughter in jail. But he did so because he wanted her to be
clean.
He came home from work and parked his police car behind his
daughter's car so he could block off, not just her car, but
also her path back to addiction. He wanted to keep his daughter
from leaving in the middle of the night. He wanted to separate
her, he wanted to protect her, he wanted to trap her. A
father's love can be a benevolent trap. But heroin is a trap,
too.
So Kevin woke up one morning to the ominous sound of an
empty house and the ominous sight of tire tracks through the
front yard. His little girl was gone again, 6 o'clock in the
morning.
Brooke went to a gas station. She called her sponsor. Her
sponsor said, ``Call your dad.'' But she didn't want to
disappoint her father again. So she drove to a church where she
played basketball as a child, crawled into the backseat of her
car, and overdosed on heroin.
It's not the statistics. It's not the money. It's something
you can't count. It's the grief of parents burying their child.
The gentleman from Maryland is recognized.
Mr. Cummings. Thank you very much, Mr. Chairman.
The first overdose death that I heard of, I was 6 years
old, 6. I'm 67 now. And this young man was a hero in our
neighborhood, and I didn't even know what drugs were.
Then I had an opportunity later on in my life, as a 15-year
old working in the drugstore, to watch people come in trying to
get Robitussin. Do you remember that? Trying to get high.
People that were in so much pain, they didn't even know they
were in pain, of all colors.
That was 50-some years ago. And I am glad that we are
moving to this moment, because I do believe that this is a
destiny moment where we say enough is enough.
Fighting the opioid epidemic has been one of my top
priorities for several years. I had a family member to die from
this. Not only because it's a terrible thing that has destroyed
so many Baltimoreans lives, but also because it's devastating a
Nation, in red states, in blue states, in purple states.
It is time that we finally recognize this epidemic for
truly what it is, a national emergency that is killing 115
Americans every single day, 115, and counting.
In December, the Centers For Disease Control and Prevention
warned that life expectancy in the United States dropped for
the second year in a row, and drug overdoses are the single
biggest reason why. In 2016, nearly 64,000 Americans died from
drug overdoses. These numbers are only getting worse with every
passing minute.
I understand that today's hearing is supposed to be about
proposals to reauthorize the Office of National Drug Control
Policy. But it's hard to do that when we have not been able to
speak to the acting director of that office. We asked for him
to testify here today, but our request was denied.
It's also hard to do it when we will not be hearing from
other stakeholder agencies that are involved in this fight,
like the DEA and the Coast Guard.
We're supposed to markup a bill next week, but we have not
received any official feedback or technical assistance from the
administration. We had a roundtable meeting with ONDCP
staffers, and I thank you, Mr. Chairman for that, but I'm
concerned that this legislation may not be ready for primetime.
Compounding this problem is the Trump administration's
total lack of leadership on this issue, and they are simply
missing in action. The National Drug Control Strategy was due
in February, but they did not submit one. Remember what I said.
We've got 115 people dying a day, but no drug control strategy.
Now, the President has just assumed office. I got that. So
maybe it is understandable. But this February also came and
went, and he still has not submitted a strategy, 115 people
dying a day.
ONDCP staff told us that Kellyanne Conway is calling the
shots. I sent a letter to the chairman on February 16, 2018,
asking for a briefing from her, or anyone, from the White House
who could tell us what's going on. But that never happened.
Ladies and gentlemen, this is the most deadly national
health crisis we have seen in three decades, in three decades.
Where President Trump has shown no leadership, Congress must
step into the void and demonstrate a bipartisan commitment to
taking on this fight in an effective and efficient manner.
We could talk all we want about how we might want to
reorganize ONDCP, require new reports, and reshuffle the lines
of authority. But they are not doing their jobs now. They are
already failing to do what Congress required. So I have little
hope that these kinds of changes alone will make a difference.
Here is the main point I would like to convey today, and I
would like to place it in the DNA of every cell of our brains.
Reauthorizing ONDCP is an important step. We want to ensure
that we have a coordinated, effective, and efficient and
evidence-based strategy.
But rearranging the deck chairs is not enough. Nibbling at
the edges is not adequate. If someone has a gaping wound, we
cannot just slap a Band-Aid on it. If someone is fatally
hemorrhaging, we cannot just hand them a new organizational
chart for a government office. They need expert medical care.
As a Nation, we need to dedicate significant and sustained
new funding for treatment to combat this epidemic. The
Department of Health and Human Services estimates that more
than 2 million people in this country have opioid use
disorders, which is likely an undercount. Yet, only 10 percent
are able to access the specialty treatments they need.
Imagine 10 people with cancer and you tell them that only
one of you can get the treatment in the United States of
America, with one of the greatest health systems ever found.
Something is wrong with that picture. We cannot stop this
crisis if 90 percent of those affected cannot be treated.
Last month, I introduced the CARE Act with Senator
Elizabeth Warren to start treating the opioid crisis like the
public health crisis it is. Our bill is modeled directly on the
Ryan White Act, which Congress passed with bipartisan support
in 1990 to address the AIDS crisis. This has been endorsed by
more than 30 organizations, including health advocacy groups,
nursing organizations, local government associations, and
public health organizations.
I urge all of my colleagues on both sides of the aisle to
join our bill. My staff has already contacted each of your
offices, and my door is open to answer any your questions.
To conclude, I want to thank our witnesses for being here
today, including Ms. Goodwin from GAO, Mr. Parekh from the
Bipartisan Policy Center.
I look forward to hearing from Mr. Carr, an old friend and
the executive director of the Washington/Baltimore HIDTA,
Intensity Trafficking Area. I appreciate his effective
leadership and I thank him for his endorsement of the CARE Act.
Finally, I thank Commissioner Gupta of the West Virginia
Bureau for Public Health for joining us today.
And as I close, let me say this. This is our watch. This is
our watch. And it is our duty to protect our neighbors. I think
the chairman said it quite eloquently. We've got to do things
to protect our neighbors.
And it will affect all of us. There was one time that it
seemed that the only place that was affected was the areas like
the one I live in today and lived in for 35 years, the Black
community.
Well, hello, there's a big difference now. It's everywhere.
And so we have to address this in a bipartisan way, and I'm
looking forward to it.
And, Mr. Chairman, I want to thank you for working with me
and for your indulgence.
Chairman Gowdy. The gentleman from Maryland yields back.
We're pleased to introduce our second panel of witnesses.
Dr.Anand Parekh, chief medical advisor of the Bipartisan Policy
Center. Dr.Rahul Gupta, commissioner and State health officer
of the Department of Health and Human Resources' Bureau for
Public Health, State of West Virginia. Mr. Thomas Carr,
executive director of the Washington/Baltimore High Intensity
Drug Trafficking Areas Program. And Ms. Gretta Goodwin,
Director of Homeland Security and Justice at the Government
Accountability Office.
We welcome all of you. Pursuant to committee rules, I must
administer an oath, so I would ask you to please stand and
raise your right hand.
Do you solemnly swear that the testimony you are about to
give should be the truth, the whole truth, and nothing but the
truth, so help you God?
May the record reflect all the witnesses answered in the
affirmative.
You may take your seats.
There's a series of lights that should inform and instruct
you. Just be aware that all members have your opening statement
in full, so if you could summarize the salient points within
the 5 minutes, that will allow more time for the members to ask
questions.
With that, Dr.Parekh, you are recognized.
PANEL II
STATEMENT OF ANAND PAREKH
Dr. Parekh. Chairman Gowdy, Ranking Member Cummings, and
members of the committee, thank you for the opportunity to
appear before you today.
I applaud the committee's efforts over the last year to
identify ways to strengthen the White House Office of National
Drug Control Policy and enhance the Federal response to the
opioid epidemic.
My testimony today is based on my perspective as a
physician, a former deputy assistant secretary of health at the
Department of Health and Human Services, and now currently as
chief medical advisor at the Bipartisan Policy Center, a
nonprofit organization that combines the best ideas from both
parties to promote health, security, and opportunity for all
Americans.
As the chairman and the ranking member noted, in 2016
alone, 2.1 million Americans had an opioid use disorder and
over 42,000 Americans died from overdosing on opioids. This
crisis, 20 years in the making, will get worse before it gets
better.
Fortunately, there are evidence-based interventions and
solutions that, if scaled by the combined efforts of the public
and private sectors, can bend the curve of the epidemic.
The Bipartisan Policy Center's Governors Council, made of
up former governors, has previously recommended four critical
approaches to tackling the opioid epidemic.
Number one, curbing overprescribing. In 2016, 91.8 million
adults, nearly 4 in 10 adults in this country, used
prescription opioids. As a physician, I can tell you there is
no reason, neither for acute pain nor chronic pain, that this
many Americans should be prescribed or be using these drugs.
Number two, curbing the illicit supply, specifically heroin
and synthetic opioids, which are currently driving the
evidence.
Number three, facilitating treatment and recovery through
increased training of healthcare professionals and medication-
assisted treatment, public and private insurance coverage of
these services, and increased funding to support the treatment
infrastructure. We have made it far too difficult in this
country to treat opioid addiction.
And number four, educating America to reduce stigma and
expand evidence-based harm-reduction strategies, such as making
Naloxone more widely available.
In order to coordinate the Federal response the Bipartisan
Policy Center's Governors Council has also recommended that
ONDCP be reauthorized, adequately funding and staffed, and
empowered to track all Federal drug control initiatives.
On that issue, I would like to make three key points to the
committee today in response to the bipartisan discussion draft
to codify ONDCP.
First, the opioid epidemic is a multidimensional public
policy challenge spanning public health, criminal justice,
macroeconomics, international diplomacy, and homeland security.
In order to comprehensively tackle the opioid epidemic, it
is critical that States and communities have a Federal partner
that has itself coordinated. The Federal response requires a
leadership office, such as ONDCP, to ensure coordination and
collaboration of executive branch agencies and departments that
have a role in addressing the supply side and demand side of
this epidemic.
The committee's envisioned National Opioid Crisis Response
Plan, with goals, measures, targets, action steps and
designations of responsible offices or officials, is urgently
needed. This plan would also more clearly inform Congress about
the appropriate Federal funding levels necessary to address the
epidemic over the next several years.
Second, the robust performance measurement and data
collection activities that the committee envisions for ONDCP
will require sufficient funding and staffing support. I
encourage the committee to ensure ONDCP tracks both process
measures and outcome measures to gauge progress in combating
the epidemic.
The critical drug control information and evidence plan the
committee is envisioning should include assurances from ONDCP
that performance metrics can be tracked using existing data
surveillance systems or that systems be developed if not
currently in operation.
I also encourage the committee to build in some flexibility
with respect to performance measurement. The committee should
ensure agency accountability while not being overly
prescriptive.
And third, for ONDCP to truly succeed it must be empowered
by Congress and supported by the administration. The President
should underscore ONDCP's authorities to Federal agencies and
departments who must be accountable for their role in
implementation of the response plan.
Ultimately, ONDCP needs to be the quarterback of the
Federal response to the opioid epidemic and needs the staffing,
funding, and authority so it can lead and inspire disparate
agencies and departments in tackling the opioid epidemic and
other threats that may come down the road.
Thank you for the opportunity to address this committee.
And I look forward to your questions.
[Prepared statement of Dr. Parekh follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Chairman Gowdy. Thank you,Dr. Parekh.
Dr.Gupta.
STATEMENT OF RAHUL GUPTA
Dr. Gupta. Chairman Gowdy, Ranking Member Cummings, and
distinguished committee members, thank you for the opportunity
to appear in front of you today to discuss an issue of
significant importance to the lives the American people, the
opioid epidemic.
State and territorial health agencies are on the front
lines responding to the current crisis of substance misuse,
addiction, and drug overdose.
As a public health official and as a practicing physician
for nearly 25 years, I have witnessed the consequence of this
crisis in the form of overdose deaths, substance-related
interaction with the criminal justice and welfare systems, HIV,
hepatitis, prenatal substance exposure effects, and the burden
on the healthcare system.
This crisis is unweaving the very fabric of our society.
In West Virginia, we continue to experience the highest
rate of overdose fatalities in the Nation. We are also enduring
a surge in the rate of neonatal abstinence syndrome among
infants, a condition in which babies are born drug-dependent.
Currently, 1 in 20 babies are diagnosed with NAS, and 1 in 6
expecting mothers are found to have intrauterine exposure to
drugs.
Children are being placed in foster care at a higher rate
than ever before, causing a tremendous demand on the social and
early childhood resources. In fact, we estimate that there is
an additional cost of at least $1 million for each baby born
with NAS diagnosis.
Our State is not alone. The number of babies born in the
United States with a drug withdrawal symptom has quadrupled
over the last 15 years.
Under the leadership of Governor Jim Justice, West Virginia
has made significant strides to take major steps in the right
direction. Last year, we conducted a social autopsy of deaths
and then engaged the public, a broad array of stakeholders and
experts, to inform policymaking.
Throughout this initiative, there was significant support
for reducing the harms of overprescribing, improving access to
evidence-based treatment, and increasing the use of Naloxone
and other harm-reduction strategies. I would be happy to share
with you the findings today.
Recently, as a practicing internist, I saw a young woman
who was brought into the clinic by her teenage daughter, being
afraid of going through withdrawals, and having received
Naloxone so many times that she was told she would not get it
again. She was desperate to enter treatment. And we got her
into treatment, but it wasn't easy.
But for three other patients that afternoon, I tried every
possible way, but the best I could do was to listen to their
story, their struggles, counsel them, offering them help
whenever they were ready.
As I left the clinic that afternoon, I sincerely hoped we
would be able to help these folks before they became a
statistic.
Today, as we keep these real Americans in mind, I would
like to stress upon three major points in my testimony.
One, to develop a sustainable solution to this contemporary
challenge, we must have authentic national leadership that can
envision and coordinate robust and wide-ranging, cross-cutting
support from multiple organizations to develop an evidence-
based comprehensive response strategy.
ONDCP provides this leadership. As the committee explores
the reauthorization, its position should be strengthened,
resourced, and allowed the expertise to develop robust
leadership potential. ONDCP has done in recent years more to
narrow the divide between public health and public safety than
any other agency.
Second, Congress and States must work towards further
expanding access to evidence-based treatment. We know that
there are a number of barriers in accessing treatment,
including stigma, homelessness, and poverty.
Individuals often need ancillary services, such as housing,
recovery support, employment assistance and training, childcare
support, and others.
Therefore, we should consider establishing a program to
provide treatment and services to individuals with substance
use disorders modeled on the Ryan White program, which provides
treatment for AIDS patients.
With that in mind, I urge you to ensure that any changes in
statute are building upon the existing system and programs that
currently exist without creating an undue burden to State and
local communities.
And finally, we must understand that this fight has to be
fought on multiple fronts. In order to fully address this
epidemic as well as substance use and misuse disorders as a
whole, we must move further upstream to address the exposures
during the life course that can lead to addiction, such as
toxic stress in infants and adverse childhood experiences.
We must bolster efforts to work with schools, school-age
children, build resilient communities, and increase investments
in programs that work to address the social-psychological
determinants of health.
In conclusion, the opioid crisis and substance misuse will
not be solved by an individual agency or State. Instead, we
need a comprehensive science-driven approach. As my patient
rebuilds her life, she is going to need addressing her health,
her home, her community, and the relationships with having a
purpose in life.
So I applaud your commitment, and I implore the committee
to take swift action.
Thank you.
[Prepared statement of Dr. Gupta follows:]
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Chairman Gowdy. Thank you, Doctor.
Mr. Carr.
STATEMENT OF THOMAS CARR
Mr. Carr. Chairman Gowdy, Ranking Member Cummings--and,
Congressman, it's nice to see you back in the office again.
Mr. Cummings. It's good to be back.
Mr. Carr. And distinguished members of the committee, it's
an honor to appear before you today to discuss the proposed
transfer of the HIDTA Program and the revitalization of the
Office of National Drug Control Policy.
I come to you today as a representative of the National
HIDTA Directors Association, but also with a sense of deja vu,
since 13 years ago to this month I testified against a similar
proposal that was before this committee. That proposal would
have transferred HIDTA to the Department of Justice, and I'm
glad to say it was rejected by Congress, and I urge you to do
the same with this iteration.
The administration's rationale for the proposed transfer is
to improve coordination among drug enforcement efforts. I
submit the coordination that the proposal claims to seek
already exists in the HIDTA program.
The most significant feature of the HIDTA program is a
longstanding policy that each HIDTA is managed by an executive
board. Moreover, the voting power on that executive board must
be equally divided between Federal and State and local and
tribal agencies.
The executive board is vital to the success of the HIDTA
program, and it has unlimited discretion over activities and
ensures that each HIDTA can tailor its strategy to the
situation in that neighborhood.
In 2017, HIDTA has funded 825 initiatives. More than 22,000
personnel participated in these initiatives. As a result of the
discretion afforded the executive boards, the makeup of the
executive boards, and the top-to-bottom commitment to
interagency cooperation, HIDTAs have established a track record
of quickly devising and implementing creative responses to the
drug challenges.
I said earlier I had a sense of deja vu. And I think you
should know that since 2005, HIDTAs have disrupted on average
2,882 drug trafficking organizations each year. They've
dismantled 17,000 methamphetamine labs, taken more than 7,700
tons of drugs off the street, including 44 tons of fentanyl,
heroin, and prescription drugs, seized $8.5 billion in cash,
and provided training for 556,000 personnel.
Now, as impressive as these statistics are, they don't tell
the whole story, so let me tell you a little bit more about it.
One of the things we did was we developed something called
the Heroin Response Strategy. This is the first
multidisciplinary approach that I'm aware of that was focused
on combating heroin and opium. The initiative brings public
health and public safety partners together to reduce overdose
fatalities. Common sense, if you ask me.
The HRS includes 10 HIDTAs in 22 States. And I think it's
important to note that in their recent review of the HIDTA
program the GAO states, and I quote: ``As demonstrated through
its management of programs like HIDTA's HRS, an agency like
ONDCP is uniquely positioned to collaborate with its law
enforcement and public health counterparts.''
GAO also recognized that a major obstacle to dealing with
the opioid crisis has been the lack of shared methodology to
track overdoses in real time across jurisdictions.
In 2017, the Washington/Baltimore HIDTA developed what we
call ODMAP to address this need. ODMAP tracks overdoses as one
would track a disease and issues alerts to public safety and
health agencies about overdose spikes. More than 650 agencies
across the country are now using ODMAP to share information.
So what makes this all possible? Well, we believe the
discretion, balance, and independence of the executive boards
is a direct result of the HIDTA program being administered by
the Office of the National Drug Control Policy.
As you're well aware, ONDCP is charged with preparing a
National Drug Control Strategy. Key to ONDCP's strength is its
ability to coordinate the formulation of the President's drug
control budget. It needs that hammer.
ONDCP's responsibilities cross the entire spectrum of drug
activities, including enforcement, treatment, and prevention,
and we believe those responsibilities give ONDCP the unique
perspective to accept a wide variety of approaches to the
opioid epidemic.
It is more urgent today than ever before for ONDCP to be
reauthorized to continue its mission. Our members and our
executive boards believe that the HIDTA program has been
extremely efficient and effective under ONDCP and there's no
evidence that demonstrates any benefits from moving the HIDTA
program out of ONDCP.
We think the neutrality of the HIDTA program is a key
ingredient for its success, and we also know that it would be
difficult for DOJ to remain neutral and objective should they
become our parent agency. Further, our non-DOJ representatives,
and there are many, believe DOJ cannot operate as a neutral
broker as well as ONDCP.
The success of the DOJ is determined by how well each of
its agencies fulfills the mission of the Attorney General. The
success of the HIDTA is determined by how well it carries out
the assignments given to it by the executive board.
So as was cited before, we have 115 people dying every day
from this crisis. We cannot afford now to abandon the ONDCP,
abandon our mission, and we have to move forward.
And I thank you very much.
[Prepared statement of Mr. Carr follows:]
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Chairman Gowdy. Thank you.
Ms. Goodwin.
STATEMENT OF GRETTA GOODWIN
Ms. Goodwin. Chairman Gowdy, Ranking Member Cummings, and
members of the committee, I am pleased to be here today to
discuss GAO's recent work on combating the opioid problem,
including the role of the Office of National Drug Control
Policy, ONDCP.
Today, I will talk with you about two topics.
First, Federal agencies' opioid-related strategies and the
extent to which each agency is measuring its performance.
Second, Federal agencies' efforts to enhance collaboration
and information-sharing to limit the availability of illicit
opioids, the ongoing challenges to doing so, and ONDCP's role
in that process.
In particular, there are five strategies that ONDCP and the
Department of Justice have implemented to specifically combat
illicit opioids. These include ONDCP's Heroin Availability
Reduction Plan, HARP, and DOJ's 360 Strategy, which the Drug
Enforcement Administration implements.
We found that of the five strategies, only one, HARP,
included outcome measures or measures that are results-
oriented. The others either did not include performance
measures at all our measured outputs instead of outcomes.
For example, one of the goals in the HARP is to
significantly reduce the number of heroin-involved deaths.
ONDCP measures its progress towards this goal in part by using
cause-of-death data. This is an example of a strategy with a
clearly defined goal and a quantifiable measure that helps
officials understand outcomes.
Most importantly, an outcome measure of this kind helps the
agency understand if what it is trying to achieve is actually
happening.
In contrast, the 360 Strategy captures the number of
participants attending its activities, which is an output.
Measuring outputs has some utility, but it does not allow the
agency to assess the impact of its efforts or whether or not
the resources it is investing are yielding the intended result.
We recommended that ONDCP and DOJ develop outcome-oriented
performance measures for their respective strategies. ONDCP
raised concerns about the recommendation, and DOJ disagreed,
stating that it would be difficult to do so.
We continue to believe that our recommendations are valid
and that finding meaningful ways to measure the effectiveness
of these approaches is essential, despite being difficult.
With respect to coordination, I will touch on some of the
challenges agencies are experiencing and the role we
recommended for ONDCP.
Federal law enforcement agencies are increasingly
coordinating with the public health sector to share overdose
information. However, both sectors reported ongoing data-
sharing obstacles and related challenges with the timeliness,
accuracy, and accessibility of overdose data.
For example, toxicology results can take months to obtain,
and this affects the timeliness of data on overdose deaths.
These data are needed to anticipate and respond to threats.
Additionally, some of the data can be incomplete because
medical examiners or coroners may not always test for opioids,
especially synthetic opioids, thereby leading to inaccurate or
incomplete data.
Further, legal restrictions to protect patient privacy on
how data can be shared and analyzed affect how much information
law enforcement and public health officials can access and
share, respectively.
ONDCP is uniquely positioned to collaborate with its law
enforcement and public health counterparts to identify
solutions to these challenges. We recommended that ONDCP lead a
specific review on ways to improve the timeliness, accuracy,
and accessibility of overdose data. ONDCP neither agreed nor
disagreed with our recommendation, but did say it would
consider it.
I will note that during our review the lack of timely,
accurate, and accessible information was one of the most
pervasive concerns we heard from the public health and law
enforcement officials we interviewed.
Given ONDCP's role in framing a national strategy, GAO
believes the agency should bring together law enforcement and
public health officials to improve national-level data and
support data-improvement efforts at the State and local levels.
Chairman Gowdy, Ranking Member Cummings, and members of the
committee, this concludes my remarks. I am happy to answer any
questions you have.
[Prepared statement of Ms. Goodwin follows:]
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Chairman Gowdy. Thank you.
The gentleman from Alabama is recognized for his questions.
Mr. Palmer. Thank you, Mr. Chairman. We've talked about the
overdose deaths, the crisis that we have there. And first of
all, I think we're talking about 64,000 people possibly that
died last year. I think that is understated.
Dr.Parekh, in your experience, are you seeing where the
death certificate does not show death by overdose but perhaps
natural causes?
Dr. Parekh. I think you're right. I think that's probably
an underestimate. Certainly, the 42,000 for opioids is likely
an underestimate as well. A lot of times the death certificates
don't get into the specific cause of drug overdose deaths.
Toxicology reports take a long time.
So, unfortunately, these are likely underestimates, and
these numbers will get worse, Congressman.
Mr. Palmer. That's what concerns me. I think Ranking Member
Cummings made this point, that the CDC has lowered the life
expectancy for Americans is not just because of drug overdoses,
it's also because of suicide. For people 10 to 24 years old,
the second-leading cause of death is suicide.
And to follow up with you, are we seeing suicides that are
linked to drug abuse?
Dr. Parekh. We are. And these are overall called the deaths
of despair. So you see drugs, alcohol, suicides taking a toll
across the country, leading to the reductions in life
expectancy, as you suggested.
There are lot of factors here, economic factors as well,
that lead to this, but they all, unfortunately, interrelated
and driving the lowering of life expectancy, as you cited.
Mr. Palmer. Well, it ought to be shocking to people that
the suicide issue for 10-year-olds to 24-year-olds is the
second-leading cause of death.
And I'm going to get into some area I probably shouldn't
get into right here, but it has to do with the number of
children, the percentage of children that are on psychotropic
drugs that have adverse effects that might lead them to other
issues like opioid abuse.
I mean, in my own district it's no longer shocking to hear
that a young high school student has committed suicide. We had
a 1-week period where a high school that's 4 miles from my
house had two in 1 week, and another one just a few miles from
there.
Mr. Palmer. And I think when we're looking at this crisis,
we've got to look at the totality. It's just not the people who
are dying from overdose, it's also the suicide aspect and link
it all together. I think if we did, we would all just be
shocked at the total numbers.
I mean, we've got veterans, 22 a day committing suicide. I
wonder if any of you have any information about that, any of
those related to adverse reactions to drugs that cause them to
have these suicidal tendancies. Do you know anything about
that?
Dr. Parekh. I think they're all--I'll start--I think
they're all--they can all be related, they're interrelated. I
think, Congressman, what you're getting at is the overall
importance of looking at the determinants of health and taking
a prevention approach.
Mr. Palmer. Exactly.
Dr. Parekh. I think the Drug-Free Communities Program, for
example, is trying exactly to do that with community
coalitions. But that's what we need to do, prevention,
prevention, prevention, look at the underlying causes, the
determinants of health. That's the best way to reduce all these
deaths of despair, whether it's drugs, alcohol, or suicide.
Mr. Palmer. Well, there is profiling can be done through
looking at DNA before anyone is prescribed a drug that would
lay down some markers about the effectiveness of the drugs and
the propensity to lead them to other things. I think that might
be part of the solution.
Mr. Carr, we're talking about fentanyl, and one of the
things that I talked about with some of the folks in law
enforcement is that they're now deploying dogs that can sniff
this out, particularly what's coming in the mail. A lot of this
is coming from China. A lot it is produced by North Koreans.
I made this comment to former Governor Chris Christie, that
we've gone from a war on drugs to a war with drugs, it seems
like, and thousands of Americans are falling victim.
One of my concerns is, and I don't know if you can answer
this, is that if we're going to try to interdict this through
the mail, what are we doing to interdict it through the mail
that goes from Mexico and to Central America and Canada that
comes across our border?
Mr. Carr. Congressman, that's a big problem. One of the
biggest facilitators of drug trafficking by virtue of the fact
that they are such good shippers is the U.S. Postal Service.
I know there are efforts underway that the U.S. Postal
Inspection Service has that are using computers and computer
programs to profile packages. We're working with them right now
with our ODMAP project, because when we detect spikes in
overdoses in geographic areas, then we hope to work backwards
and target the packages that did come and are coming into that
particular area so we can be more effective in the
interdiction.
But one of the problems with the way that they are shipping
now is the fact that they are shotgunning. They are not sending
big loads, they are sending multiple, multiple smaller loads.
So it takes a lot of manpower and time to pick off those loads.
And so if we got to 10 percent--I'll pick a number out of the
air--we got 10 percent of them, 90 percent of them are still
getting through, which is still a problem.
Can I go back to one comment you made, and it touched on
prevention. We're using the ACEs model, Adverse Childhood
Experiences, to help us profile young children.
We are working with the schools in Jefferson County, West
Virginia, particularly the city of Martinsburg, the police, the
schools, the board of education, the counselors in the schools,
public health officials, all working together to identify those
kids most at risk and to do something not only with them, but
with their parents.
And that's the future of this, we have to look at long-term
prevention if we're going to be successful in it.
Mr. Palmer. I agree 100 percent.
Mr. Chairman, if I may, I just want to comment on your
opening comments. One of the things that indicates how
widespread and serious this crisis is, I don't think I know
anyone who does not have a personal story of a friend or a
colleague or a family member similar to what you delivered. And
I thank you for that and for your indulgence.
And I yield back.
Chairman Gowdy. The gentleman from Alabama yields back.
The gentleman from Massachusetts is recognized.
Mr. Lynch. Thank you, Mr. Chairman.
And I want to thank the witnesses for coming here and
trying to help us grapple with this problem.
Just referring back to the gentleman from Alabama's
comments regarding suicide, in my district a few years ago we
had a suicide cluster. And I lost 14 young boys, the oldest
probably 17, the youngest probably 14, in a very short period.
And there is definitely a correlation between this opioid
epidemic, not one-to-one correlation, but there is definitely a
connection there with the desperation that comes with
addiction, and then these young people have no way out.
The problem is bigger than that, but I think the gentleman
from Alabama is spot on in trying to identify, drill down on
that, and deal with that.
In our community I didn't know what to do. I reached out to
CDC and a lot of other folks. I reached out to my construction
unions. We actually built a residential facility for young
people. Because up to that point we were actually collocating
kids with adults, which is a bad situation.
But we established a Cushing House for boys, and now we've
established a Cushing House for girls. It is an adolescent
residential facility dealing with this problem. And got the
support of the Tufts Medical Center and also my local community
health center and set it up. But the line is out the door.
We've got 40 beds and I've got a list probably several hundred
long trying to get in.
I was touched by the chairman's initial remarks. There's
42,000 stories out there last year alone of similar situations
with families losing their kids.
I do want to say that step one, though, is to have the
director of the Office of National Drug Control Policy at this
hearing, at that table right there. And we did not ask him to
come here, and that just blows my mind. Because this is all
about accountability.
And I'm proud of Congress because the last bill that we put
out has $3.5 billion to deal with this problem and we don't
have a director here who is willing to testify. We don't have a
President that has a drug policy that we can articulate to
families out there that are in the situations that we just
described. We are dragging our feet on this and this is
inexcusable.
And each witness here has talked about having leadership on
this issue and a direction and a strategy on this issue, and we
have a big fat zero because President Trump has somebody there
for 8 months and that didn't work out. And now we've got a new
person and we won't even ask him to come here and describe what
the President's policy is because we don't have one. So we've
got $3.5 billion to support a policy that does not exist at
this point, and that is inexcusable.
I've got 2 minutes left.
Let me ask you, Dr. Parekh and Dr. Gupta, so there's a
strategy for the Suboxone. It is a replacement therapy when our
kids are hooked on opioids. And they are handing this stuff out
like candy. And we're replacing opioid addiction with Suboxone
addiction, which is also an opiate.
And I don't see any improvement there. We're just
substituting drugs, one drug for another drug, and we're
spending a lot of money on it. And I end up with an addict in
each case.
Can I get your sense of this?
Dr. Parekh. Thank you, Congressman.
So I think the short answer is, in fact, they are different
drugs. One is a full opioid, the other is a partial opioid.
That makes a big difference. And it allows this Buprenorphine
or Suboxone to actually treat opioid addiction. And the best
evidence we have, the gold standard evidence for treatment of
opioid----
Mr. Lynch. I'm down to 45 seconds.
My follow up, Dr. Gupta, Vivitrol, it's another version,
it's a nonopiate, it doesn't seem to have the abuse potential
that some others do. I that you didn't come prepared for this,
but that's my question, is it better?
Dr. Gupta. Congressman, what I would say, just like
diabetes or any other chronic disease, this is a chronic brain
relapsing disease. We wouldn't tell somebody with diabetes
don't take insulin, because otherwise you are artificially
giving insulin, what your body's missing. Just like this.
These drugs go, they have been studied, they do four
things. They prevent relapse into the system, they prevent
overdoses and deaths, they reduce infectious disease risk, and
lastly, they reduce the risk of somebody having criminal
activity.
So there are documented, evidence-based measures behind the
use of MAT in the population. The best science we have today,
it seems to work.
Mr. Lynch. Okay.
Mr. Chairman, thank you for your indulgence, and I yield
back.
Chairman Gowdy. The gentleman from Massachusetts yields
back. I will tell the gentleman, my friend from Massachusetts,
that the nominee was invited to the roundtable. And I am
disappointed that he did not come. The membership participation
was good and----
Mr. Lynch. Well, I apologize then.
Chairman Gowdy. No, no, no.
Mr. Lynch. I did not know that he was invited.
Chairman Gowdy. He was invited.
Mr. Lynch. You ought to subpoena him if he didn't come.
Chairman Gowdy. I think it would have benefited him and us
to have him present, but he decided not to do so.
The gentleman from North Carolina, Mr. Meadows.
Mr. Meadows. Thank you, Mr. Chairman.
And I thank both sides of the aisle for their heart and
passion on this particular issue, because it does affect every
community.
And yet, at the same time, it is critically important that
we recognize that as important as it may be to have a new
director of this agency/subset of the executive branch, it is
far more critical that we actually start doing something about
it. Because this did not start with this administration. We've
had this issue for a long time. And I know the gentleman from
Massachusetts would agree with that.
I do agree that it should be all hands on deck. And I think
the problem that you're hearing is a frustration of the fact
that we have a drug that is being used and there are so many
deaths each and every day, as, Ms. Goodwin, as you pointed out
that, that we've got to deal with it.
Now the other thing is--and I would encourage--the ranking
member of this committee has been very vocal in this area and I
appreciate his leadership. It also goes into other areas, like
FDA. We've got to find other alternatives for pain management
that are, quite frankly, in the hopper waiting to be approved.
And so we need to work in a bipartisan way on areas that
perhaps have a less addictive nature. This was supposed to be
the wonder drug and it has really taken over in a critical
area.
Ms. Goodwin, I want to come to you, because you talked
about the coordination and where we are and that it's critical
that we have coordination. And yet I think what I understand
is, is so whether it's the DEA coordinating with the Coast
Guard, coordinating with other areas on domestic illegal
synthetic opioids, GAO found that only one of five strategies
it reviewed actually included a results-oriented matrix or
measurement. Is that correct?
Ms. Goodwin. That's correct. So we looked at the five
strategies that are out there and the only one that had a
performance-related metric was the HARP program.
Mr. Meadows. Okay. So if we have five programs and only one
of them has a measurement, how do we know when we're succeeding
or making progress? Is it all just----
Ms. Goodwin. Well, that's something we recommended. In our
recommendation we submitted to ONDCP we talked about the need
for them to come together and kind of pull all of those
strategies together, have a conversation, and help each of
those strategies develop metrics. Because you can't really get
to the heart of the problem or begin to address the problem if
you don't have evidence-based information.
Mr. Meadows. So if it is evidence-based, I think we will
find Democrats and Republicans alike that will want to look and
say: Are we making progress here?
And what you're saying is, is that the only progress that
we see currently is really whether deaths go down from
overdose? I mean, how do we measure whether we're making
progress with any policy, no matter how great it is? What would
be your recommendation?
Ms. Goodwin. We didn't talk through or we don't put out
there as GAO like what each of the entities are supposed to do.
We ask that ONDCP start a review to develop a strategy that
crosses all of the different stakeholders.
And working very closely with the public health officials,
law enforcement, and the other stakeholders, we think that's a
way to come to a strategy and begin to think about----
Mr. Meadows. Yeah, let me interrupt because I've only got 1
minute left. And I appreciate your answer.
But I guess my question is, if you've identified it as a
concern, you obviously have areas that you believe need to be
measured, do you not?
Ms. Goodwin. Yes.
Mr. Meadows. So have you made those recommendations in the
areas that need to be measured? Because you just said you
didn't make a recommendation. But when you're doing the
analysis, you have to run across what your areas of concern
are.
Ms. Goodwin. Yeah, one of things we are look for when we
are doing our analysis, when we looked at HARP we noticed that
they were actually collecting data, paying attention to the
information, and reporting out. The other four strategies we
looked at were just measuring whether someone showed up to a
meeting or participated in an activity. We didn't feel like
that that went a long enough way----
Mr. Meadows. Far enough.
Ms. Goodwin. --went far enough to actually getting at a
conversation about what's the extent of the problem, what's the
nature of the problem, and how can you best develop strategies
around that.
So when GAO goes in to look at something the first thing we
want to know is, where are the data? And we weren't finding the
type of data we thought would be useful for this conversation.
Mr. Meadows. So, Mr. Chairman, may I offer this. In a
bipartisan fashion, I know you have made this a priority for
the reauthorization and really moving forward.
Mr. Chairman, I know where your heart is, I know where the
heart of the ranking member is on this particular issue. And if
we only reauthorize, to not actually have a plan that
implements with a measurable tool like Ms. Goodwin did, we will
have failed.
And so I'm committed to work in a bipartisan fashion with
both of you on the leadership on this particular issue. I thank
you.
Chairman Gowdy. I thank the gentleman from North Carolina.
The gentlelady from Illinois is recognized.
Ms. Kelly. Thank you, Mr. Chair.
And I just wanted to let the ranking member know that I can
really relate to what you were saying. When I was much, much,
much younger than I am now, a little girl, I lost an aunt to
heroin. She had three children and her oldest daughter died of
a heroin overdose, a dirty needle. So this is something near
and dear to me.
One of the most critical tools in addressing the opioid
epidemic is the overdose reversal drug Naloxone. Naloxone is a
generic drug. It was first approved in 1971. Yet the prices of
these products have increased so dramatically in recent years
that State and local communities are now having trouble
stocking the drug. They are being forced to ration. One of
these products, an auto injector like the EpiPen, now costs
$4,500 for a pack of two.
Dr. Gupta, as part of West Virginia's opioid response plan,
all first responders are now required to carry Naloxone. Is
that correct?
Dr. Gupta. Yes, Congresswoman.
Ms. Kelly. And some of the first responders are from
volunteer organizations. Isn't that correct?
Dr. Gupta. That is very true.
Ms. Kelly. So how does the price of Naloxone affect the
ability of first responders to adequately equip themselves?
Dr. Gupta. I think that's the important part. So one of the
things that Governor Justice did, he actually put money behind,
State money. So he's put about $10 million into the plan, with
specifically $1 million, and repurchased over 37 doses of
Naloxone with State money. And we got about $26 a piece. But
smaller agencies do not have that capacity and ability to have
the purchasing power to do that.
And we are very worried that the price increases and the
price policies that are created are going to be a stumbling
block no matter how many discounts are given, how many free
Naloxone is distributed.
We're afraid that the average person who needs it isn't
going to be able to get it because they feel it's something
that's, while life saving, is also extremely expensive in their
perspective.
Ms. Kelly. One of my hospitals I know has a program and
they give it to our law enforcement in my rural area of my
district.
We've heard similar testimony from county officials who
testified at a hearing on the opioid epidemic last month in our
Health Subcommittee. One witness said because of price
increases local communities have to, and I quote, ``fly by the
seat of our pants all the time in terms of coming up with the
medication.''
Dr. Gupta, from a public health perspective, how do these
pricing issues affect your ability to truly combat this
epidemic?
Dr. Gupta. Congresswoman, I can tell you from data, when we
conducted a social autopsy we found that of the people EMS went
to who have died from overdose, only a third of them actually
got the Naloxone. And when we talk about elderly and African
American, it was even worse.
So what we're seeing is that people are having--we have
evidence to show that people--first responders are having to
decide who to give, who not to give. And then there is always
the issue of stigma because folks think that maybe the elderly
aren't dying because of overdose. So that adds to the problem.
Ms. Kelly. The CARE Act, which I am cosponsoring, would
invest $500 million per year in a Naloxone distribution
program. Under this program the Federal Government would
negotiate discounted prices for the product and then distribute
it to the States, to first responders, local health officials,
and the public.
Would this kind of Federal role in negotiating, purchasing,
and distribution of the product help West Virginia equip your
first responders in your community?
Dr. Gupta. Yes, Congresswoman, that would be critical in
ability to help that person. Because, again, if they have to
have breath in their lungs in order to meaningfully have a
chance to enter treatment, then we have to build the rest of
the system as well to make sure that those folks, we save them
first and then provide them the help. But this would be very
helpful.
Ms. Kelly. And I think we would all agree that it is
unacceptable that communities all across the country are health
hostage by these arbitrary price increases, especially for a
life-saving drug. And it is also unacceptable that drug
companies would use the opioid crisis as a way to profiteer at
the expense of all of our constituents.
And I'm interested in working in a bipartisan way to see
how we can combat this issue. And also I hope my colleagues
will help by cosponsoring the CARE Act so we can bring these
prices down and provide States and local communities with the
tools they need to address the problem.
I yield back.
Chairman Gowdy. The gentlelady yields back.
Dr. DesJarlais.
Mr. DesJarlais. I thank the chairman and thank the panel
for being here today.
Ms. Goodwin, I'll start with you. I've met with many groups
over the years that stress the importance of instituting a
nationwide prescription database. As you know, or may know,
Tennessee borders eight different States and the congressional
district I represent borders two.
This poses a unique problem because in the absence of a
nationwide prescription database, drug abusers in my district
will frequently get a prescription for an opioid in Tennessee
and then simply cross the border into Alabama or Georgia and
attempt to fill another.
What steps are you taking to address this problem?
Ms. Goodwin. So GAO has not looked into that specifically.
When we did some of our review, we did talk to a number of
representatives from the HIDTA program. So I think actually Mr.
Carr can speak more eloquently to that than GAO could.
Mr. Carr. Thank you, Congressman. I'll try.
Several years ago we were detecting people that were
getting prescriptions written for them in Kentucky and they
were driving to Miami to fill them. I don't know how many
pharmacies they passed on the way. So I think you can know what
they are up to.
With the PDMP that's been implemented, prescription drug
monitoring program, I think that's a good first step. There are
some issues with PDMP in that they are all activated at the
State level. So in some cases doctors are required in that
State to look at the PDMP to find out if their patient before
them has in fact been given a prescription for an opioid or the
like by another doctor.
In other States however, it is only recommended and they
don't have to look. So I think we need to do some more work on
that.
I think, personally speaking, I think a national database
makes sense, especially as fluid as our population is today.
Mr. DesJarlais. And I would agree with you. Thank you.
This is for any of the panelists, regarding hospice care.
Under the current law, to my understanding, hospice care staff
are not allowed to dispose of the patient's prescriptions when
the patient passes away. This often leaves the family sometimes
taking narcotics or opioids home with them, or they may end up
in their medicine cabinet and be forgot about, or somehow taken
out of the home. And it leads to an increase of the drugs being
distributed back into the community.
What safeguards can we enact to ensure that this problem is
dealt with?
Dr. Gupta. Thank you, Congressman.
I think it's important for us to be able to have either,
again, the take back days, as well as enhanced efforts to
destroy the medications going back to.
I think we're get to go a place where opioids as they are
in the market are going to have to have companion mechanisms
dispensed to patients to be able to destroy the medications.
Also a blister pack. We've just enacted laws to limit the
initial prescribing in ERs and outpatient. So what happens? We
would like to see blister packs for 3 days' or 7 days' use and
then a parallel system where they can put it in a package and
then destroy it. So I think that technology is needed.
Nationalizing, I just want to be real careful about that,
because we need systems that will connect State PDMPs with
other State PDMPs, rather than federalizing or nationalizing,
because we are able to use our data in ways, creative ways in
advance as a laboratory in States that would be a little bit
difficult from federalizing the PDMP.
Dr. Parekh. Congressman, I'll just add that FDA, I think
Dr. Gupta is absolutely correct, FDA is looking into this
blister pack idea and I think that's very, very promising.
To your point, there are 15 billion pills of opioids
dispensed every year. Only 6 billion, 40 percent, are consumed.
So 9 billion pills are, as you suggest, going different places
and oftentimes end up in families' medicine cabinets.
Mr. DesJarlais. If you can answer this for me, I've heard
that of the prescription opioid related deaths, over 90 percent
of those are not the person that the drug was originally
prescribed to. Is that your understanding?
Dr. Parekh. I think it's a large number. There are 11
million Americans who are misusing opioids. Either they didn't
have a prescription or they are not following the prescription.
Mr. DesJarlais. So I mean think that's a really important
point to drive home, is that the physicians that are
prescribing the opioids were doing that at a lower rate, but
the opioids are getting in the wrong hands. And there needs to
be a focus on punishment for distributing controlled
substances, and the patients need to be educated before they
leave the office and probably at the pharmacy as well.
And if the chairman would indulge just one last question, I
recently met with a group of pharmacists that explained to me
how e-prescribing can prevent overprescribing opioids by
allowing healthcare providers to see a patient's medication
history at the point of care, thereby helping them determine if
the patients are doctor shopping.
Have any of you all been paying attention to this movement
in States toward electronic prescribing for controlled
substances? And if so, have the results been positive?
Dr. Gupta. Congressman, I would say that we have attempted
to do that in West Virginia. One of the challenges, I go back
to this rural America divide, is that we have places we don't
even have broadband in West Virginia. We have places where
physicians rely on fax to transmit data.
So I think this links to another issue that we really have,
which is e-prescribing is only good as the ability to get to
our practices in sometimes the rural parts of the State, and
that's a limiting factor. But we do have some type, but it is
very hard to be more robust in that.
Mr. DesJarlais. I thank the panel for their expertise.
I yield back, Chairman.
Chairman Gowdy. The gentleman yields back.
Mr. DeSaulnier.
Mr. DeSaulnier. Thank you, Mr. Chairman. I want to thank
you for this hearing.
And I want to thank the ranking member for his passion and
his urgency.
And I want to thank the panel members. This has been really
interesting.
I guess my question is in two parts. One part is the
urgency of getting this right and the suffering that the
ranking member talked about.
And all of us, I think, anecdotally have had experiences,
personally perhaps, but definitely professionally in this
regard. I have constituents who have come to me over the years
who have lost sons and daughters, and many of them are from
very diverse economic aspects of my district in the bay area.
So my question is, Dr. Gupta, you are really in a very
unique position, I think, given the challenges of West
Virginia, so the urgency of getting out now. But you said at
some point we have to go upstream to look at the real cause and
effect.
So there are stories in the book of ``Dreamland,'' which is
a compelling book that you've had a chance to read about, the
evolution and the causes of this, some of it ascribed to Purdue
Pharma and aspects of their marketing. So in that case, there's
pretty good evidence that they targeted the marketing
specifically to West Virginia and other areas where they knew
there was a lot of manual labor. Surely it seems intuitively
that they targeted the worker's compensation system, permanent
disability.
So how does that make you feel? And if you have evidence. I
know my county just joined a whole group of counties in
California in suing Purdue Pharma and others, because they have
caused us to spend money, as you said, $1 million per child.
And the context of my question is, I'm a survivor of an
incurable cancer. I have remarkable medicine that will keep me
alive, keep my quality of life high. I just had a meeting with
constituents who work at the University of California were
involved in the CRISPR system there. Looked like, very
promisingly, we can use genetics to identify bacteria in our
system.
So I look at the system and the sustainability question of
the urgency of now. But then how can we learn from this to
really transform, given the context of what medical research is
giving us right now?
If we could take the money that we're spending on that
child, multiplied towards whatever number, and put it into
these programs that can avoid this thing happening in the first
place, including private sector companies or organized crime,
using the system to divert our limited resources to stop this.
So you were at the front lines of this. Could you respond
to that?
Dr. Gupta. Thank you, Congressman, very much for that
question.
You know, we as physicians began prescribing for pain, and
we ended up over the years treating suffering instead of pain.
And that's what we have today.
When we conducted our social autopsy of all the deaths in
2016 from overdoses in West Virginia what we found was four out
of five people actually came in contact with the health system.
We were having a lot of lost opportunities that we could have
helped these people.
But as a result, what we found was if you're 35 to 54 years
old, single, male, less than high school educated or high
school, and work in a blue collar industry, you have a very
high risk of dying because of an opioid overdose.
How we work is we are also seeing, again, a tremendous and
such a demand on child welfare. We worry about the next
generation as we sit here. We're losing 10, 15 years from now
those babies being born now that are going into schools. These
are the kids who are going to have lifelong traumatic
experiences.
So as we work to address social determinants of health, as
my colleagues have mentioned, we have got to look at those
things. We've got to look at childhood experiences, we have got
to look at traumatic communities, and we have to then work.
NAS, for example, we have programs now looking at long-
acting reversible contraceptives as part of the corrections
system. Our corrections officers know the way they are making
the math right now, doing the math, they are saying 33.5
correction officers equals $1 million a year investment, 37
inmates equals $1 million dollars a year.
So they are saying we have thousands and thousands of
people that need MAT. We don't we start doing MAT instead of
putting people in prison?
So there's this relationship that is developing in trying
to get folks to actually go through science- and evidenced-
based treatment on one hand, save lives on the other hand, and
are connecting those for treatment, and then really working
upstream.
It's really not a partisan issue for us to look at how do
we help a woman actually get into treatment before she starts
to plan a family? I mean, this is just a social responsibility
because we are seeing the other side of this in society so
much.
We recently had a person, 82-year old great-grandmother,
taking custody of a child. Those are the examples we are seeing
on the ground every single day.
Mr. DeSaulnier. I really appreciate that.
And to the chair and the ranking member, I really think
this is an amazing opportunity for us in Congress to change the
dynamics on these reoccurring public health crises, to really
look at the cause and effect. And not to ascribe blame to the
private sector or anybody, but to look at evidence-based and
say, not only can we sell the opioid program, but all of us can
remember being told 20 years ago that crack babies were going
to cost us money. We fall in this pattern of these reoccurring
public health crises that maybe we can approach in a different
way and avoid these unnecessary costs in human suffering
dollars.
Thank you, Mr. Chairman.
Chairman Gowdy. The gentleman yields back.
The gentleman from Maryland is recognized.
Mr. Cummings. First of all, I want to thank all of you for
this excellent testimony.
You know, one thing you didn't mention, Dr. Gupta, and I
was looking at a CNN piece on West Virginia, was foster care,
the cost of foster care, because the parents are dead or they
are on drugs. Can you comment on that very, very briefly?
Dr. Gupta. Yes. Thank you, Mr. Ranking Member.
We are not even able to now find parents to foster the
children, it has become so bad. West Virginians are great,
giving people, but we at the point that we have the highest
levels we've ever seen in the history of the State in kids
entering into foster care. It is the biggest, unquestionable,
challenging burden of the future for our State and we are very
worried about that.
Dr. Gupta. Dr. Gupta, you are from West Virginia. Your
State has been hit extremely hard by this epidemic. This issue
does not discriminate based on politics. It affects red States,
blue States, and purple States.
Last November we held a hearing with Governor Chris
Christie of New Jersey who chaired the President's opioid
commission. The commission stated only about 10 percent of
those who need treatment receive it and they warned that people
are, and I quote, ``losing their lives as a result of it.''
Dr. Gupta, is that right? Are people dying today because
they simply can't access treatment? Is that true?
Dr. Gupta. That's absolutely correct and very true. And
part of the reason is the stigma. It's not just they can't
receive treatment. Some people worry they are going to lose
their job. Some people think that they don't have enough
coverage, they can't travel to get treatment. They have to in
West Virginia average wait 30 to 60 days before they can enter
outpatient treatment.
So we have so many barriers, including stigma, why people
can't get treatment and as a result end up dying.
Mr. Cummings. You know, I mean, there's a big elephant in
the room, Doctor, okay? Anybody who has ever been around drug
addicts knows that quite often they end up being another
person. In other words, they begin to lie, steal.
One of my earliest cases as a lawyer was a fellow who
literally killed his--hatcheted his grandmother to death trying
to get money for drugs.
So they turn into another person. They look like the same
person, but to somebody else.
So I guess for an employer that's a kind of difficult
situation. I was just with the railroad people yesterday and
they were telling me how hard it is for them to get people to
hire, because people simply cannot pass the drug tests. And
they worry about accidents big time, and they should.
In January your State of West Virginia instituted an opioid
response plan that also called for expanded access to
treatment. It states, and I quote, ``One of the most important
actions that any State can take to address the opioid crisis is
expanding access to effective treatment.'' Is that right?
Dr. Gupta. Yes, sir, that's absolutely correct. One of the
things we did was we had State regulations for MAT clinics.
We've created exemptions for physicians so they don't have to
pay the registration, they don't have to go through the whole
process if they want to treat their own patients up to 30. We
have also cut down on onerous regulations within our State.
We are making every effort possible to make MAT treatment--
and MAT is just not drugs, it's a whole host of behavioral,
social, cognitive therapies that go along with it--as the
primary focus of our effort to make sure that every West
Virginian who has an opportunity, wants to get into treatment,
has no delay, treatment on demand type of----
Mr. Cummings. And I gave you the 10 percent figure
nationally that are able to get treatment. What's it like in
West Virginia? Do you have any idea?
Dr. Gupta. We have wait times, as I mentioned. There is a
great COAT Program at West Virginia University and their
average wait times are between 30 and 60 days.
So you can imagine what happens in those 30 days, because
people don't wait 30 days when they have this monster on their
head that they have to worry about every time, getting a dose
in 3, 6 hours, sometimes even more frequent.
Mr. Cummings. So here is the big question. We here on the
committee can talk about organizing ONDCP. We can discuss
moving things around on an organizational basis. We can even
ask ONDCP to send us more reports. But if that's all we do, if
we fail to ensure sustained funding to expand access to
treatment, will we be able to turn this crisis around as a
Nation?
And I know I've run out of time, but I want you also to
just speak very briefly. We spend a lot of time talking about
deaths, but we've got a pipeline. I'm talking about the living
and the dead. Because a pipeline car is far bigger than the
folks, the 1 in 15 I am talking about, that are dying daily.
So would you comment on that, Dr. Gupta?
Dr. Gupta. Certainly, sir. One of the things I would say is
that every person who has an opioid overdose, nonfatal, that
comes in, it's a cry for help basically. What they are saying
is that is suicide attempt, because they know every time it's
Russian roulette when they inject that drug.
The question is, are we able to then connect that cry for
help and get those people immediate treatment? We are working
on that in West Virginia, trying to make sure that every
emergency room visit, first of all, that it doesn't happen, but
if it happens, how do we connect that cry for help back to
treatment, they get that treatment. There's a lot more people,
it's the tip of the iceberg beneath that.
So the first thing is to avoid deaths. This is a
preventable problem. This is something we can prevent and get
people into treatment. Everyone that dies we see, they had,
four out of five people, came into context with the health
system and we failed them, to be really honest.
Mr. Cummings. How do you see us getting past the stigma?
And that's a tough one. The stigma on the part of the patient--
I mean, the drug addict.
But there's another stigma, too, that we haven't talked
about here: the doctor. A lot of doctors don't know how to
treat this stuff. You know, they see a drug addict come in and
they say: Aw, no, no, no, no, no, no. They don't want to touch
it.
So talk about that and how you deal with that end of it in
West Virginia.
Thank you, Mr. Chairman.
Dr. Gupta. Yes, sir. The most important part of this
disease, how we differentiate this from perhaps the HIV, even,
the epidemic, is that the stigma of this is across the
communities, it's across the healthcare system, law
enforcement.
And there's a lot of good-intentioned, good-faith folks
trying to help, but that stigma continues. And it is that
reason that we need to have programs like harm-reduction
strategies, that people will come in, be treated in a very
nonjudgemental manner.
We have to redo the way we look at folks, we have to redo
the way we treat folks, address this problem. People don't
choose not to get treated. Folks have told me, every five times
before, we were telling them they need help, they listened,
they weren't dead and not listening. It's just that it didn't
filter in until the time they were ready.
We have to build a supportive system of that stigma,
whether it's police officers, whether the treatment,
physicians, hospitals, criminal justice system, as well as the
court system, the entire society.
I think we're far away from being able to entirely remove
stigma. We have stigma websites. We're doing everything in West
Virginia and a lot of organizations are working together. But
it's going to take every fabric of that society to undue the
stigma aspect of this problem. It's a big problem.
Mr. Cummings. I yield back.
Chairman Gowdy. The gentleman yields back.
The gentleman from Wisconsin is recognized.
Mr. Grothman. Sure. A couple of questions.
I agree with you, Dr. Gupta, that I think whenever anybody
takes heroin--and as I understand it, everybody who takes it
knows people who've died from it--there is an element, suicide
is too strong a word you, but at least you're saying that it's
not the end of the world if I die. And that's a problem.
I think it was Dr. Parekh who told--one of the two of you
in your original testimony, and I didn't see it in your written
testimony--said the number of people in this country every year
who are prescribed some sort of painkillers that could be
described as opiates, could you repeat that statistic again?
Dr. Parekh. Sure. So this is the National Survey on Drug
Use and Health in 2016. So 91.8 million American adults, nearly
4 in 10, say they've used opioids in the preceding 12 months.
Now, that could be that they were prescribed or they are
misusing.
And the misusing number is 11.5, so 11.5 million Americans
are misusing opioids. So either they didn't have a prescription
in the first place, they got it from family, friends, or they
had a prescription.
Mr. Grothman. Could you tell us the equivalent number from
other countries?
Dr. Parekh. I think, unfortunately, Congressman, this is a
uniquely American problem. We have 5 percent of the world's
population, we consume 80 percent of the world's opioids.
Mr. Grothman. Wow. So that would show it's an American
problem and it shows that other countries don't seem to have
this problem. So you wonder what they're doing differently.
Have we looked into at all the background of the average
heroin user? Do we ever study family background, religious
background, what have you?
Dr. Parekh. Other panelists may want to jump in, but I
think one statistic that is important to note is if you look at
first time heroin users, 80 percent of them first started
abusing prescription opioids. And I think that is a critical
piece.
Mr. Grothman. Okay. I mean, do we have anything else,
though, as far as demographic examples, family background,
educational background, age? Do we have those statistics, Dr.
Gupta?
Dr. Gupta. Yes, Congressman. We conducted a social autopsy
of everyone who died in 2016 in West Virginia from overdose.
What we found was typically individuals are 35 to 54 years old,
male, high school educated or less, single, and working in blue
collar industry. So this is the social autopsy.
Mr. Grothman. Single people. What about their parents? What
did we find out about their parents?
Dr. Gupta. Well, I think what we find is basically it's one
of those situations of hope.
Mr. Grothman. Not hope. But what was their background, what
type of family background did the people grow up in?
Dr. Gupta. I couldn't--yeah, I'm sorry.
Mr. Grothman. Put enough money into it. Next time you do a
study, you should check into that.
At least I felt heroin's been around this country a long
time. There was a time the stigma against taking heroin, I
mean, there was a bright line, I think, between alcohol and
marijuana or even cocaine and heroin. I know there's been a lot
of emphasis on removing the stigma.
Are you sure we want to remove that stigma? There used to
be a stigma. And I think at the time there was a stigma and
less people took heroin. But are you sure we want to remove
that stigma?
Dr. Gupta. Congressman, I'll give you an example. So 71-
year-old woman living with her children--her children living
with her--every time she started to use heroin for postherpetic
neuralgia, that's pain after you get shingles, because her
doctor took her off the Percocet, and she uses three syringes.
The first time she injects a small dose, back in a bigger
dose to make sure there's not enough fentanyl to kill her, and
then she gives herself the main dose. And that's all because
she actually trusts her dealer.
So, yeah, there's a lot of that because she wouldn't go and
get help because she thinks her family will find out and it
would be a bad thing for people to know a 71-year-old is using
heroin. So there's a tremendous amount of stigma.
Mr. Grothman. I'll give you another question. I recently
had something in my district in which a member of law
enforcement was very concerned. Somebody was pulled over with a
substantial amount of heroin, clearly a dealer, and they were
given time served or something. It really bothered the law
enforcement person because these people are probably as
dangerous as can be.
I know we're stuck on kind of a trend of saying too many
people are in prison, and there may be too many people in
prison. But to me heroin and related drugs are a new thing.
I am very concerned on hearing stories, and particularly in
more liberalish areas, of people who are dealers not really
going to a prison for a long period of time. And I know in
other countries that don't have these problems who are not as,
oh, so afraid to put somebody away, they don't have these
heroin problems either.
Usually the police aren't the problem, the police want to
put them away. But do you think our judges or the rest of the
judicial system is getting too involved in this treatment stuff
and are not sending a strong enough message to the dealers by
putting them away for long periods of time since they are
killing so many people?
Chairman Gowdy. The gentleman is out of time, but you may
answer his question.
Dr. Gupta. Congressman, I think the distinction to be made
between dealers, which obviously are bad guys, and every year
that they could be in prison for, versus the folks who have
actually gotten into this and don't understand it and have
something called substance use disorder or opioid use disorder
that actually need help, and they can be productive. It's
because the people, the majority of people we are dealing with,
they are actually workers. They are work-engaged populations.
We are losing work productivity in this country at a rate like
never before.
Chairman Gowdy. The gentleman yields back.
Mr. Grothman. I'll just point out he didn't answer my
question. But okay.
Chairman Gowdy. The gentleman yields back.
My friend from Vermont is recognized.
Mr. Welch. Thank you, Mr. Chairman. Thanks for having this
hearing. And I appreciated your opening statement.
And our ranking member, Mr. Cummings, I also want to thank
you for your incredible leadership on this, and I want to thank
the panel.
I'm from Vermont. I'm going to take advantage of the
opportunity to talk a little bit about Vermont, and I'll ask a
few questions. But I am going to take advantage of that
opportunity.
Our Governor was the first, Governor Shumlin, to dedicate
his entire State of the State, in 2011, to the problem we saw
emerging in Vermont of opioid dependence and addiction.
And I remember coming back here after the Governor did that
and my colleague saying, ``Peter, why did the Governor do that?
That's bad press for Vermont.'' And the answer from our
Governor was: We acknowledge our problem and try to face it.
That's what we did.
And then a few weeks later one colleague after another
would come up to me and say, ``You know what, we've got a
problem that's as bad or worse in my State, my district.''
And I think the fact that there was a focus on
acknowledging the issue has helped us in Vermont establish a
pretty good treatment program, the Hub and Spoke program, that
is having some significant success.
But in the past year I've been having roundtables in one
community after another, Brattleboro, Bennington, Newport, St.
Albans, and just this question of who are the victims. It's
everybody is the victim.
I mean, there are some folks who work, some folks who got
on it because they had a proclivity to use excess drugs, some
who started out with a work-related injury and got opioid
prescriptions and it led to bad things and they couldn't get
off it, others who are having a crisis of hope.
And Dr. Gupta you're ground zero in West Virginia, which
I've traveled to. And there is the real crisis here of good
people.
I don't meet people who are addicted that want to be
addicted. You know, the dealers are a separate question and
throw the book at them as far as I'm concerned, but it's a lot
of good everyday citizens who would prefer to be in the
workforce and aren't.
And this is affecting all of our communities, especially,
in my view, rural America, where there is a collapse in the
local economy. And a lot of the local institutions that have
been so important to help people have a sense of purpose and
live those rural values of helping one another, helping their
community, that's all being frayed. And we have got to have as
part of our response a revitalization of rural America. That's
my view.
But while we're trying to get there, I do believe that we
must have a Marshall Plan for attacking this, much like we did
with the HIV epidemic with the Ryan White bill. This has got no
partisan preference. Every one of us who represents our
districts have people in it who are really suffering.
And the Cummings bill, which does have a Marshall Plan
agenda, significant resources that are applied to dealing with
this issue, that is absolutely what we need. This crisis is not
going to help itself.
And by the way, on the stigma question, one of the biggest
preventions of people making that step to go into treatment is
the apprehension of how they will be labeled. And in our
roundtables, the people that were most compelling to me were
two groups.
One was the people in recovery. And every single one of
them said it was their ability to cross that line, from being
private and secret to being open and public, which is what
empowered them to take the difficult next step. And it's what
opened up the opportunity for other people in similar
situations to provide mutual support, ultimately something
really essential, as I see it.
The other group that I was really impressed with, I mean
all of them really, was law enforcement. They do not like the
dealers. Their job is to arrest people. But their message to
us: We're not going to arrest our way out of this problem. It's
not going to happen. So they saw treatment is absolutely
essential. And the biggest, biggest challenge was that people
who had gotten to that point, where they're ready for
treatment, there was no treatment available.
And that's why I believe the Cummings bill is absolutely
essential. That's the Marshall Plan that we need in order to
give folks who were ready to make that step and rid themselves
of this addiction can take it successfully.
Mr. Chairman, I'm at the end of my time.
And I thank the panel for listening to me. I really thank
you all for your work. And I'm just speaking out on behalf of
Vermonters. Thank you.
Chairman Gowdy. The gentleman from Vermont yields back.
The gentlelady from New York is recognized.
Mrs. Maloney. I thank you, Mr. Chairman. I want to thank
you and all the panelists and Mr. Cummings for focusing on what
has really become a national crisis. And I am pleased that we
are jointly looking at this.
In recent years pain has come to be called the, quote,
``fifth vital sign,'' end quote. And in many clinical settings,
including hospitals, patient pain levels have been measured
obsessively, including with the use of sad and smiley faces,
and many have warned that this focus on eliminating all pain
and getting all patients to select smiley faces spurred the
extensive use of opioids in clinical settings. And well-
intentioned policies that incorporate patient pain into quality
ratings and other measurements may have aggravated the problem.
So I want to ask Dr. Gupta, who probably has more
experience on the level with the people with the illnesses, we
want to ensure that individuals who are experiencing serious
pain, including those that are at the end of their life, get
the pain relief that they need. But on the other hand, we don't
want to move to the point that people are being inappropriately
prescribed more pain pills that they really need.
I mean, I've read some stories where patients were getting
pain treatment and got addicted, which is a tragedy. And
apparently it's a very hard deal to get off this addiction.
So one of the recommendations of the opioid response plan
you just issued in West Virginia was, and I quote from your
report, ``West Virginia should expand the authority of medical
professional boards and public health officials to address
inappropriate prescribing of pain addiction and medications.''
So, Dr. Gupta, what additional authorities do professional
boards and public health officials need in your State to
address inappropriate prescribing? And do you think that there
has been any inappropriate prescribing, in your overview?
Dr. Gupta. Thank you, Congresswoman.
There certainly has been. There were over 780 million pills
that were shipped into small towns of West Virginia. We know
that West Virginia had one of the highest prescribing rates for
opioids.
But there's good news. We've seen from 2017 data that we've
made the most progress of any State in the Nation in curbing
those prescriptions.
Specifically----
Mrs. Maloney. May I ask, of these pills that went into West
Virginia, were they illegal drugs or were they prescribed
through doctors?
Dr. Gupta. These were distributed prescription drugs that
were distributed through distributors that came in without
necessarily a check.
Governor Justice sponsored and passed with wide bipartisan
support earlier this year a bill that limits the prescription
of opioids in ER settings to 4 days, in outpatient settings for
dentists, primary, optometrists, and veterinarians to 3 days,
and for other physicians to 7 days.
So one of the things we have to do is we have to turn the
tap off for initial prescribing. Initial prescribing is sort of
your tap to getting people hooked later on, and we know from
science that beyond 3 to 5 days of prescribing really in
vulnerable population leads to this disease of addiction.
Mrs. Maloney. Whoa, 3 to 5 days? That's astronomical.
Now, is there anything that the Federal Government can do
to help you in your efforts in West Virginia in this
overprescribing?
Dr. Gupta. I think one of the things, Congresswoman, that
can do done as we move forward, we have to be cognizant about
the people when have legitimate pain. So as we go and we see
the crackdown that happens with our State and Federal partners
on pain clinics, illegitimate pain clinics, we have got to find
folks who have genuine pain to be connected back into
appropriate physicians who do prescribe.
So we want to make this where it's okay to have legitimate
pain and have prescriptions, a very important piece for a
treatment armamentarium until we develop those nonopioid
treatments.
Mrs. Maloney. Let me ask you, are the majority of people
that are overdosing in West Virginia taking opioids that have
been prescribed, either to them or someone else, or are they
taking street drugs such as the fentanyl?
Dr. Gupta. We found 9 out of 10 had prescription history;
49 percent of women filled the prescription within 30 days of
their death. Yet the death we're seeing is because of street
fentanyl and heroin. So what's happening is there is a
crossover happening, but prescription drugs still remain a
critical component of that.
Mrs. Maloney. Okay. Do harm-reduction efforts create
important opportunities to get individuals with substance use
disorders into treatment?
Dr. Gupta. Very important opportunities. We need to look at
harm reductions, such as syringe exchange programs, Naloxone
distribution, and a host of social services that go along with
that, including screening for diseases, and that as a gateway
to treatment.
Mrs. Maloney. Well, I want to thank you.
My time has expired. And I believe this is a bipartisan
issue we can work together on for treatment. Thank you.
Chairman Gowdy. The gentlelady yields back.
The gentleman from Virginia is recognized.
Mr. Connolly. Thank you, Mr. Chairman.
And welcome to our panel.
Dr.Gupta, the Senator from your State, Joe Manchin, did his
own report using the methodology used by the Council of
Economic Advisers and came up with the cost of the opioid
crisis in your State alone of $8.7 billion. Does that sound
right to you?
Dr. Gupta. Yes, sir. That's about 12 percent of the State's
GDP.
Mr. Connolly. Yeah.
Dr. Gupta. And that's extreme. But there's many other
States similarly placed, if not exact same position.
Mr. Connolly. So that would suggest whatever we're
investing or need to invest in treatment will have a huge
return on it, given that cost.
Dr. Gupta. Yes, sir.
Mr. Connolly. And obviously we're underfunding treatment
right now?
Dr. Gupta. Yes, sir.
Mr. Connolly. I don't know where to begin.
So I had a constituent whose son died. He was an athlete at
a major university in the Northeast. He had an injury. He was
prescribed opioids and he developed an addiction. He was a
motivated young man and did everything in his power to try to
kick it. He went into rehab, he went into treatment facilities.
The treatment was wrong and ultimately led him to need the
high, he moved to heroin, and he died of an overdose. Tragic,
tragic story.
I'll ask either one of you, Dr.Parekh or Dr.Gupta, are
treatment facilities regulated for this crisis, for this
problem?
Dr. Parekh. I think treatment facilities are regulated at
the State level. I think that the issue, Congressman, is that
not enough treatment facilities are offering the gold standard,
which is medication-assisted treatment.
Mr. Connolly. Well, let me go back to certification,
though. Can I put out a shingle and say, ``We've got the
expertise here to deal with your opioid crisis, give us a
call''?
Dr. Parekh. Unfortunately, that is being done right now.
Mr. Connolly. That's right. That is my point. It's not
regulated, not uniformly.
And so treatment, the idea of going for treatment, well,
what treatment? For example, the example I gave of my
constituent's son. As I understand it, correct me if I'm wrong
medically, but one of the treatment centers he went to embraced
the AA model: Go cold turkey and follow the 10 steps or 12
steps.
Well, it turns out, according to my constituent, that is
exactly the wrong thing to do. You cannot simply go cold turkey
with this addiction. It's different than alcohol. And if you
don't have some intervening treatment, you put yourself at
enormous risk. And the craving for that high will absolutely
move you to something else, heroin or fentanyl, for example,
leading to worst outcomes.
I see you shaking your head, Dr.Gupta. Is that accurate?
Dr. Gupta. Yes, Congressman. Only half of the private
treatment facilities across this country actually offered MAT.
And in that, only a third actually get MAT. MAT is the best
science-based treatment available, yet we struggle across
States.
There is going to be a small silver of the population that
maybe the 12-step works for them. But there often seems to be a
prohibition for using any mind-altering drug.
Mr. Connolly. I'm running out of time, forgive my
interruption. But my constituent argued it is actually life-
threatening. It was life-threatening for his son to go that
route, even with the best of intentions.
Dr. Gupta. Congressman, I'll add one more quick thing.
People who have opioid use disorder, having other mental
conditions is the rule, not the exception. So you have to be
treating other underlying medical conditions. And if
organization does not accept that treatment for bipolar or
depression, then you're in trouble.
Mr. Connolly. So, Ms. Goodwin, in the time I have left, the
President's own Council of Economic Advisers estimates the cost
of this crisis to the U.S. economy--we talked about West
Virginia--is a half a trillion a year. Correct?
Ms. Goodwin. Correct.
Mr. Connolly. So certainly, the President has proposed a
national strategy to deal with this, has he not?
Ms. Goodwin. Yes.
Mr. Connolly. He has? And what is that strategy?
Ms. Goodwin. So that strategy is kind of in the making.
Mr. Connolly. Oh, in the making?
Ms. Goodwin. Yes.
Mr. Connolly. Has the President declared this a national
emergency, as was recommended to him?
Ms. Goodwin. Yes, it has been declared a national
emergency.
Mr. Connolly. And what flows from that?
Ms. Goodwin. So the declaration of an emergency will mean
that the different Federal agencies will start to think through
and think about how they will address the crisis.
You may already know that GAO has ongoing work looking at
public health declarations around this crisis. That's in the
beginning stages. So we are in the process of designing the
scope and methodology for that.
Mr. Connolly. My time is up.
I want to thank the chair for having this hearing.
There is no way we can move forward without this being on a
bipartisan basis. This is a crisis that affects every
community, every socioeconomic strata. This is not something
limited to one group or another. And it's reached crisis
proportions, obviously, in the United States. So we've got to
work together to find solutions.
Thank you, Mr. Chairman.
Chairman Gowdy. The gentleman from Virginia yields back.
I'm going to go last. So I want to start by thanking the
panelists for your expertise, your commitment to helping us
combat this issue.
Dr.Gupta, what progress, if any, is being made in the
ability to objectively diagnose pain? As opposed to allowing
the patient to pick which frowny face, or on a scale of 1 to
10, which is inherently subjective, is there any progress being
made in being able to objectively diagnose pain?
Dr. Gupta. Mr. Chairman, I think there is some work in the
research and development sort of phase of this. It's been a
difficult thing from a clinical aspect to be able to diagnose
something that's very subjective. I do think efforts need to
happen there from an R&D standpoint in order to get more
objective signage. But clearly, there's a need for that.
Chairman Gowdy. Okay. So if I were to present myself at
either of the doctors--I assume you all are medical doctors or
are you Ph.D.'s? Medical doctors.
I present myself, I tell you I have pain. You are not
totally reliant upon me to quantify that, but it helps. There's
no test you could administer.
What are the alternatives to habituating prescriptions?
What are your pharmacological alternatives to something that is
habituating right now.
Dr. Gupta. First of all, we would want to make sure to do
the proper testing to find out if there's a legitimate physical
reason for it. But then again, opioids is just one part of it.
They are not very good a pain treatment to begin with. There's
other options, including nonpharmaceutical options, as well as
pharmaceutical options.
So we're talking about--back pain, for example, very
common. Most of back pain treats itself in about a couple of
weeks, so oftentimes you need supportive treatment, not really
opioids. That's something that opioids were traditionally used.
Combination of medications like acetaminophen and
ibuprofen, that really means Tylenol and Motrin put together,
tends to have, in some studies, better outcomes or better
impact on pain than does opioids.
Chairman Gowdy. Okay. You put your finger on something. I
present to one of your physician practices. I tell you I'm in
pain. I want something that I consider to be strong. You're
recommending something I could get at CVS or Walgreens.
So I've got a couple options. I can either go see another
doctor and hope for a better result. So you've got--in July we
were told--and look, I like doctors. I grew up in a house with
one. I don't get excited talking about prosecuting physicians.
But the reality is there are illicit drugs that are handled in
an improper way. And there's money to be made doing that.
So is this a misinformation issue? I mean, you just said
there are better alternatives to opiates. I assume doctors know
that. So if there are better alternatives, is it a lack of
information that allows them to prescribe it or is it the money
aspect?
Dr. Gupta. Mr. Chairman, there's a whole host of issues. In
my practice, since 2000 or so, I've been told by the industry
that these are medications that are very highly effective,
there is no potential for addiction, and all kinds of things.
If short term doesn't work, we have long-acting medications.
They are really sold and marketed as the ultimate solution, and
now we know that that's not the case.
Chairman Gowdy. All right. But you don't get to be a
medical doctor by not being bright. So the fact that some
pharmaceutical rep comes in, gives you a calendar and a key
chain, and says, ``Hey, look, you really need to prescribe this
medicine, even though I made straight C's in college, take my
word for it,'' is a doctor really going to be persuaded by a
pharmaceutical rep?
Dr. Gupta. If you look at direct-to-consumer advertising
campaigns and the pharmaceutical budgets, companies' budgets
that go into this type of work, at least the evidence
demonstrates that that strategy tends to have some impact on
the prescribing habits.
Chairman Gowdy. This will probably be over my head, but
we'll try it anyway.
What is the pharmacology of opiates that makes it so
difficult to--you know, last week they told us nicotine was the
toughest drug to beat. In a previous life, I dealt with heroin
addicts. I would list that as the toughest drug to get off of.
What is it about the pharmacology that makes it so
difficult?
Dr. Gupta. Mr. Chairman, it's the same pharmacology would
be for heroin, which is it goes and crosses your blood-brain
barrier and attaches to the receptors, the particular receptors
that gives you a pleasure to begin with, as well as a number of
other activities.
And that's the reason when people have a craving, the need
for increasing the dose continues. People go to the cheaper,
readily available street alternative. That is the same action
of receptors that we work with MAT, whether they block them,
they are partial agonists to them, or they are pure agonists.
But ultimately, the idea here is to work on the same
receptors that opioids have sort of stayed on in terms of
heroin or prescriptions and almost cause a person to become
addicted to that and have the disease of addiction.
Now, we prescriptively do that with drugs like
Buprenorphine and others to block those or actually partially
work with those receptors. So it's the same mechanism, it's
just the drugs that we talk about, MAT, are not something that
people are going to be able to get high on or overdose from in
the doses that they are prescribed. But they can, if they also
use some of the other drugs along with it, the street drugs.
Chairman Gowdy. All right. I'm out of time, and I want to
hold myself to same standard I hold my colleagues to. So I'm
going to give myself one more question after running out of
time like I do them.
I was just in your beautiful State 2 weeks ago. It's a
beautiful, beautiful place to be.
Are you satisfied with DEA's diversion, not DEA agents that
wear guns and badges, I mean the diversion, the folks who
actually monitor pharmacists and physician practices, are you
satisfied with the presence of DEA diversion in West Virginia?
Dr. Gupta. Thank you, Mr. Chairman.
West Virginia is a great State. We are very thankful for
DEA folks helping us with diversion.
One of the things that can definitely happen, we in West
Virginia have a requirement for licensees, like myself, to have
a mandatory training for opioid prescribing. That is perhaps
something--I also hold a DEA license--that is something that
perhaps needs to be nationalized where it's important for every
physician, every person going to medical school, nursing
school, anywhere they are going to be close to opioids, be able
to have a particular curriculum-based training as a part of
their practice.
That's something of an outstanding piece, but we're very
appreciative of DEA's partnership with us.
Chairman Gowdy. All right. I want to thank the members for
their participation. I especially want to thank our witnesses
for your expertise, for your comity, with a ``t,'' with each
other, and with the members, and look forward to visiting with
you again.
The hearing record will remain open for 2 weeks for any
member to submit written opening statements or questions for
the record.
If there's no further business, the committee stands
adjourned.
[Whereupon, at 1:13 p.m., the committee was adjourned.]
APPENDIX
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