[House Hearing, 115 Congress]
[From the U.S. Government Publishing Office]
[H.A.S.C. No. 115-110]
MILITARY HEALTH SYSTEM REFORM:
PAIN MANAGEMENT, OPIOIDS
PRESCRIPTION MANAGEMENT
AND REPORTING TRANSPARENCY
__________
HEARING
BEFORE THE
SUBCOMMITTEE ON MILITARY PERSONNEL
OF THE
COMMITTEE ON ARMED SERVICES
HOUSE OF REPRESENTATIVES
ONE HUNDRED FIFTEENTH CONGRESS
SECOND SESSION
__________
HEARING HELD
JUNE 20, 2018
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
__________
U.S. GOVERNMENT PUBLISHING OFFICE
33-383 WASHINGTON : 2019
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SUBCOMMITTEE ON MILITARY PERSONNEL
MIKE COFFMAN, Colorado, Chairman
WALTER B. JONES, North Carolina JACKIE SPEIER, California
STEVE RUSSELL, Oklahoma ROBERT A. BRADY, Pennsylvania
DON BACON, Nebraska NIKI TSONGAS, Massachusetts
MARTHA McSALLY, Arizona RUBEN GALLEGO, Arizona
RALPH LEE ABRAHAM, Louisiana CAROL SHEA-PORTER, New Hampshire
TRENT KELLY, Mississippi JACKY ROSEN, Nevada
(Vacancy)
Glen Diehl, Professional Staff Member
Craig Greene, Professional Staff Member
Danielle Steitz, Clerk
C O N T E N T S
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Page
STATEMENTS PRESENTED BY MEMBERS OF CONGRESS
Coffman, Hon. Mike, a Representative from Colorado, Chairman,
Subcommittee on Military Personnel............................. 1
Speier, Hon. Jackie, a Representative from California, Ranking
Member, Subcommittee on Military Personnel..................... 2
WITNESSES
Bono, VADM Raquel C., M.D., USN, Director, Defense Health Agency;
and CAPT Mike Colston, M.D., USN, Director, Mental Health
Policy and Oversight, Office of the Assistant Secretary of
Defense for Health Affairs..................................... 3
APPENDIX
Prepared Statements:
Bono, VADM Raquel C., joint with CAPT Mike Colston........... 20
Coffman, Hon. Mike........................................... 19
Documents Submitted for the Record:
[There were no Documents submitted.]
Witness Responses to Questions Asked During the Hearing:
[The information was not available at the time of printing.]
Questions Submitted by Members Post Hearing:
Ms. Tsongas.................................................. 37
MILITARY HEALTH SYSTEM REFORM:
PAIN MANAGEMENT, OPIOIDS PRESCRIPTION MANAGEMENT AND REPORTING
TRANSPARENCY
----------
House of Representatives,
Committee on Armed Services,
Subcommittee on Military Personnel,
Washington, DC, Wednesday, June 20, 2018.
The subcommittee met, pursuant to call, at 3:30 p.m., in
room 2212, Rayburn House Office Building, Hon. Mike Coffman
(chairman of the subcommittee) presiding.
OPENING STATEMENT OF HON. MIKE COFFMAN, A REPRESENTATIVE FROM
COLORADO, CHAIRMAN, SUBCOMMITTEE ON MILITARY PERSONNEL
Mr. Coffman. I want to welcome everyone to the Military
Personnel Subcommittee's hearing on ``Military Health System
Reform: Pain Management, Opioids Prescription Management and
Reporting Transparency.'' Our panel includes the Director of
the Defense Health Agency and the Director of Mental Health
Policy and Oversight for the Assistant Secretary of Defense for
Health Affairs.
They are here to address opioid abuse, an important problem
that has affected every congressional district in the United
States. The opioid epidemic in the United States claims roughly
116 people from drug overdoses every day; 42,249 people died
from overdosing on opioids in 2016 with an estimated cost of
over $504 billion. With the military being a vital subset of
the overall population that may encounter stresses related to
deployment, training, and family separations, understanding the
magnitude of opioid abuse and the challenges related to overall
pain management is a critical part of the Military Personnel
Subcommittee's congressional oversight efforts. We are here
today to understand the scope of the opioid abuses, abuse
issues in the military and with non-Active Duty TRICARE
beneficiaries. Our panel will also address policy reform on
opioids from a strategic enterprise perspective and the
Department of Defense model for pain management.
The subcommittee is also concerned with the Department of
Defense's efforts to ensure reporting transparency with State
prescription drug monitoring programs. We understand there have
been some challenges with developing a State prescription drug
monitoring programs, PDMPs, model that balances military
related cybersecurity and operational concerns with the need
for data transparency with nonmilitary treatment facility
clinicians and pharmacists that are serving TRICARE
beneficiaries accessing multiple points of healthcare services.
I ask unanimous consent that nonsubcommittee members be
allowed to participate in today's briefing after all
subcommittee members have had an opportunity to ask questions.
Is there objection?
Without objection, [nonsubcommittee] members will be
recognized at the appropriate time for 5 minutes.
Before I introduce our panel, let me offer Congresswoman
Speier an opportunity to make any opening remarks.
[The prepared statement of Mr. Coffman can be found in the
Appendix on page 19.]
STATEMENT OF HON. JACKIE SPEIER, A REPRESENTATIVE FROM
CALIFORNIA, RANKING MEMBER, SUBCOMMITTEE ON MILITARY PERSONNEL
Ms. Speier. Mr. Chairman, thank you, and I am delighted
that after a couple of opportunities to have this hearing that
had to be postponed, we welcome our individuals who are
testifying today, and I want to thank the chairman for having
this hearing because, indeed, it is a crisis in our country.
When we have over 2 million people over the age of 12 who are
either dependent on opioids or are abusing them, it is time for
us to take very seriously the impacts on everyone, none the
least our service members, their dependents, and retirees. I
think the military has the opportunity to lead the Nation to
reduce opioid abuse and develop alternative pain management
therapies, and today I am eager to hear about your efforts to
exercise such leadership.
Several years ago, the military realized it had an opioid
problem when it became clear that the predominant pain
treatment for our wounded warriors was prescription medication.
Changing prescribing practices and increasing the use of
alternative pain management methods has enabled the military to
reduce the prescription opioid abuse among Active Duty service
members to 1 percent.
However, opioid abuse remains a challenge, especially for
retirees and dependents. I am interested in hearing how the
Department's new opioid prescription guidance will be
implemented to limit the amount of days for each prescription,
as well as how the DHA [Defense Health Agency] will implement
it if it becomes law, the NDAA [National Defense Authorization
Act] requirement to create a Prescription Drug Monitoring
Program to increase transparency with States as well as reduce
prescription monitoring.
I am also interested in hearing about how DHA will lead
research on and increase the availability of alternative pain
methods like acupuncture, chiropractic care, and other services
that are now being utilized by healthcare providers around the
country.
So with that, Mr. Chairman, I yield back.
Mr. Coffman. Thank you Ranking Member Speier. We will give
each witness the opportunity to present his or her testimony
and each member an opportunity to question the witnesses for 5
minutes.
We would also respectfully remind the witnesses to
summarize to the greatest extent possible the high points of
your written testimony in 5 minutes or less. Your written
comments and statements will be made part of the hearing
record.
Let me welcome our panel: Vice Admiral Raquel C. Bono,
Medical Corps, United States Navy, Director, Defense Health
Agency; and Captain Mike Colston, Medical Corps, United States
Navy, Director of Mental Health Policy and Oversight, Office of
the Assistant Secretary of Defense for Health Affairs.
Vice Admiral Bono, you are now recognized for 5 minutes.
STATEMENTS OF VADM RAQUEL C. BONO, M.D., USN, DIRECTOR, DEFENSE
HEALTH AGENCY; AND CAPT MIKE COLSTON, M.D., USN, DIRECTOR,
MENTAL HEALTH POLICY AND OVERSIGHT, OFFICE OF THE ASSISTANT
SECRETARY OF DEFENSE FOR HEALTH AFFAIRS
Admiral Bono. Thank you, sir. Chairman Coffman, Ranking
Member Speier, and members of the subcommittee, I am honored
here to be alongside with Captain Colston, who serves as our
senior clinical policy expert for DOD [Department of Defense]
on issues related to pain management and opioid abuse issues.
I want to thank the committee for your continued support
and investments in pain management research and opioid
addiction.
The Military Health System's mission is to ensure the
medical readiness of our Nation's Armed Forces and to provide
world-class healthcare for all of our 9.4 million
beneficiaries.
The Military Health System is also part of the larger U.S.
health system, and we have a shared responsibility to take
action and help address the Nation's public health crisis
regarding opioid abuse and addiction.
Today, what I would like to do is outline what we know
about the current state of opioid issues and addiction among
DOD beneficiaries, highlight the steps the Department is taking
to address this crisis, describe the partnerships we have built
across the public and private sectors, and, finally, to
describe our efforts to enhance our ability to share our data
on our beneficiaries with State prescription drug monitoring
programs.
The Department has made strides in managing opioid abuse
within our system and is continuously looking to further
enhance our programs. Fewer than 1 percent of our Active Duty
forces either abuse or are addicted to opioids, and our
overdose death rate among Active Duty is one-quarter the
national average.
Chronic opioid use is more common among our patients who
are 45 years or older, and they are more likely to be retirees
or family members of retirees, and they receive the majority of
their care outside of our military hospitals and clinics.
Just last week, the Department published the Defense Health
Agency Procedural Instruction for Pain Management and Opioid
Safety, which establishes the MHS [Military Health System]
stepped-care model as the comprehensive standardized pain
management framework for providing consistent, quality, and
safe care for patients with pain with an emphasis on
nonpharmacologic therapies.
With the help of this model, we have reduced opioid
prescriptions by 15 percent. We plan to further reduce this
rate through a focus on nonpharmacologic therapies within the
military treatment facilities and through direct care policy
changes.
Working closely with our pharmacy contractor, Express
Scripts, Incorporated, ESI, we are closely monitoring the
distribution of opioids across all venues, military pharmacies,
civilian retail pharmacies, and our mail-order system. We are
identifying high users of opioids and sharing that information
with our providers within the military treatment facilities. We
have also taken measures to minimize complications for patients
requiring opioids. We are able to monitor the daily morphine
intake of those patients requiring opioid therapy and easily
identify those at increased risk for death from opioids. We
have a patient lookup tool that calculates the risk of overdose
or serious opioid-induced respiratory depression to assist
providers in safe opioid prescribing. Naloxone is readily
available through the pharmacy and the military treatment
facilities to be dispensed to eligible beneficiaries upon
beneficiary request or when the pharmacist determines elevated
risk for life-threatening opiate overdose using the patient
lookup tool.
In addition, the new TRICARE managed care contracts require
our contract partners to act on information provided by DOD on
a quarterly basis regarding patients with unusually high or
lengthy opioid use, as well as providers who prescribe high
amounts of opioids.
And we have been working with ESI to establish a
prescription drug monitoring program, PDMP, that will connect
with the States. This provides a key tool in the opioid fight
as it will allow DOD providers to access State PDMPs, as well
as allow civilian providers to access the DOD PDMP.
Although prescriptions filled for DOD beneficiaries through
mail or retail venues are readily reported to the States, the
establishment of the DOD PDMP will provide a full controlled
substance profile for all providers and pharmacists. Our DOD
PDMP solution will operate through a commercially available
portal and hub technology that not only allows us to
bidirectionally share DOD controlled substance information with
a State but addresses operational security concerns. I expect
this new capability to be available by December 2018.
Mr. Chairman, Madam Ranking Member, this crisis is touching
the lives of so many of our fellow citizens, and the Department
is committed to playing its part to help combat the epidemic
and ensure our patients receive the finest care we can provide.
DOD is making headway, but there is more to be done educating
our patients and providers on threats from opioid addiction and
strategies to reduce abuse.
Thank you for asking us to be here today. Between myself
and Captain Colston, who is deeply involved in this issue day
to day, I look forward to addressing all of your questions.
Thank you.
[The joint prepared statement of Admiral Bono and Captain
Colston can be found in the Appendix on page 20.]
Mr. Coffman. Thank you, Admiral Bono.
How is the Department of Defense planning to ensure
compliance and transparency reporting with the State
prescription drug monitoring programs, and how do we know this
is the right model?
Admiral Bono. Sir, this is a model that has been in use by
many of the States, and so with what we are doing with making
our data available to the State PDMPs is by adhering to their
practices and their requirements for participation. It is
bidirectional, and so, we have found a way to make sure that
our data is completely visible to them.
Mr. Coffman. Okay. Admiral Bono, or Captain Colston, what
steps or processes are we putting in place to wean service
members off of opioids, and is this tracked across the Military
Health System?
Captain Colston. Yes, sir, it is. So, in fact, opiate use
is down even over the last year in Active Duty service members
from 3.2 percent to 2.7 percent. We have introduced a stepped-
care model with regard to the way that we treat pain that puts
an emphasis on nonpharmacologic therapy and wants to take
people off of opiates. We want acute pain not to become chronic
pain, and we want to be able to treat both acute and chronic
pain without opiates.
There are several methods to detox someone from opiates
that we approach clinically, and, of course, for folks who
struggle with both pain disorders and opiate use disorders, we
have a full suite of medication-assisted therapy available both
in network and in MTFs [military treatment facilities].
Mr. Coffman. Okay. Admiral Bono, anything to add to that?
Admiral Bono. No, sir, this is very comprehensive, and
Captain Colston described it well.
Mr. Coffman. Very well.
Admiral Bono, are we considering healthcare industry best
practices when it comes to management of opioids? Please
provide some examples.
Admiral Bono. Yes, sir. Yes. As a matter of fact, the
stepped-care model that we are using was done in partnership
with the VA [Department of Veterans Affairs] and was validated
with them. We are also working with NIH [National Institutes of
Health], and we are also working with West Virginia. And part
of the research that we have been able to do is not only
collaborate across these institutions but also validate that
the tools that we are using are effective. The pain scale that
we use, the Defense Veterans Pain Scale, is something that we
have done in partnership with the VA. So many of the tools that
you see in use here have not only been done with best practices
in civilian and academic centers, but it has been validated by
them, as well.
Mr. Coffman. Thank you Admiral Bono.
Ranking Member Speier.
Ms. Speier. Thank you, Mr. Chairman.
Thank you, Admiral and Captain. I would like to spend a
little time on the CDC [Centers for Disease Control and
Prevention] guidelines. The CDC guidelines recommend immediate
release of opioids, not extended. They recommend less than 3
days' supply and suggest that 7 days will rarely be needed and
not to allow the use of benzodiazepines at the same time. So
that is the recommendations by the CDC, and I am wondering why
your recommendations, your guidelines are, frankly, much more
liberal than that? In fact, I believe you have 7 days as your
floor, which to me is more than twice what is being recommended
by CDC.
Admiral Bono. So, for minor procedures and acute pain, we
actually recommend 5, and we also are looking at the morphine
milligram equivalent to keep that below 90 per day. In that
case, too, for acute and minor procedures, there can only be
refill on that prescription for 3 days only if evaluated by a
provider. For major procedures, we do--we recommend 7 days,
but, again, refill can only be done after evaluation by a
provider and with maintaining a morphine milligram equivalent
below 90.
Ms. Speier. You are not quite answering my question. Let me
just read to you one of the other recommendations. It says that
when considering increasing dosage to more than 50 morphine
milligram equivalents per day and should avoid increasing
dosage to 90 milligrams per day or carefully justify a decision
to titrate dosage to 98 milligrams per day. I guess my point
is, is that you are exceeding the guidelines in some ways
significantly from what the CDC is recommending, and I want to
know why.
Admiral Bono. While I am familiar with the CDC guidelines,
I think what I was trying to share is how we stratified it
between minor procedures and major procedures, and so I would
probably need to understand it a little bit more, and perhaps I
might be missing something in the question, if I could----
Ms. Speier. Ask the Captain?
Admiral Bono. Yes. One of my lifelines.
Captain Colston. Ma'am, so most folks get much, much less
than 50 morphine milligram equivalents per day. For dental
procedures, it is 1 day with 1-day refill. For short-term pain
or acute procedures or small procedures, it is 5 days with a 3-
day refill, and again, most people don't get opiates at all for
these types of procedures. For major procedures, 10 days with 7
days.
I can tell you from personal experience, most of the time,
you don't get opiates. I just broke my foot in four places, and
I didn't get a shred of opiates. Recovered faster, felt much
better.
The overwhelming--there is a consensus both between CDC and
the VA-DOD guidelines that we don't want to use opiates. We
would much rather use other modalities for pain, and if we are
going to use a pharmacological approach, we want to use non-
opiates. When you look at the amount of opiates that we are
prescribing in the system, that number is down precipitously,
and I have seen this evolve over the last 5 years.
Ms. Speier. Okay. I am running out of time. So I think you
have gotten my point. You might want to go back and look at
whether you need to reduce it a little bit more. I have a
subsequent question on--is it gabarbardine or--do you know
what, Doctor? Gabapentin. And are you using that in lieu of
opioids, or is that considered an opioid?
Captain Colston. Yes, ma'am.
Ms. Speier. All right. Can I just make a point there
because I was just talking to a doctor because I am about to
have surgery, and he was saying now the abuse is shifting from
opioids to this particular drug, so I think we should just be
on the lookout that if we are just substituting one drug for
another and it still has addictive qualities, that that is a
problem as well.
But I would like to just shift gears for the little time
that I have left to asking about these alternative pain
management methods, the use of acupuncture, relaxation therapy,
chiropractic care. Are there plans to expand these treatments
to all MTFs, and if they are not currently available in MTFs
can beneficiary receive treatments in the civilian network?
Admiral Bono. Yes, ma'am. So 83 percent of our MTFs
currently offer some kind of complementary modality. I am
actively looking to see how we can make sure that all
beneficiaries have availability or access to these
complementary treatments and have started studying how
commercial and private plans are including this and what we can
do to make sure that we have this in our health plan for all
beneficiaries.
Ms. Speier. So you are saying, at 80 percent you have at
least one of these, but you may not have all of them. Is that
what you are saying?
Admiral Bono. Yes, ma'am. At least one. There may be a
combination depending with acupuncture, meditation, and
alternate pain treatment modalities.
Ms. Speier. And do you have that chilling system that many
hospitals are now using in lieu of opioids?
Admiral Bono. I am sorry?
Ms. Speier. There is some system where you can put a
chilling--I am way above my pay grade. I think I will just--I
will yield back.
Admiral Bono. I will Google it, if I may.
Mr. Coffman. Dr. Abraham.
Dr. Abraham. Thank you, Mr. Chairman.
If you guys are only got a 1 percent rate, you guys are
phenomenally doing a great job, I can tell you, because we
know, compared to the civilian population, that is way below.
So kudos to what you are doing.
A couple questions. Admiral, you said there was a 15
percent reduction. Is that in the young Active troop, or is
that in the troop that maybe has retired that has comorbid
conditions, such as arthritis, degenerative disk disease, or
something like that?
Admiral Bono. These are primarily with the patients that
are being treated in our MTFs.
Dr. Abraham. So that is a young troop. Good deal. You
mentioned naloxone, what we call Narcan.
Admiral Bono. Yes, sir.
Dr. Abraham. And we know that that can be immediately
lifesaving, and it seemed like the caregiver is able to access
that if it is deemed necessary for that particular individual.
Is that a correct statement?
Admiral Bono. Yes, sir.
Dr. Abraham. Do you guys track the amount of Narcan that is
used?
Admiral Bono. We have just--I just signed off on the policy
that allows us to dispense the Narcan from our pharmacies,
making that available to prescribers as well as pharmacists
who--so we are just now going to be able to start tracking that
in real time.
Dr. Abraham. And you said by April of 2019 or December of
2018, you will be linking up with some of the States. Have you
guys got a pilot program already in place?
Admiral Bono. December of 2018.
Dr. Abraham. So this year?
Admiral Bono. Yes, sir. We will be able to communicate with
all State PDMPs.
Dr. Abraham. I am from Louisiana, and we have a pretty good
reporting system there, and it does make a difference as far
as--I mean, if I can punch up a patient and see that they are
seeking from another physician, then, you know, we go in and we
have a little discussion with them, so.
Admiral Bono. Yes, sir. Our patient lookup tool allows
providers like Captain Colston to look up day or night into the
patient's profile, so that has been very helpful.
Dr. Abraham. Okay. And, you know, again, we understand the
necessity of getting this right. We certainly understand the
severity of the problem, not only in the military but across
the spectrum.
Kudos to you, Captain, if you had four breaks and did not
take an opioid.
Admiral Bono. That is because he did not have many days
off.
Dr. Abraham. And we probably rightly and maybe wrongly do
vilify the opioid drug, but like any particular drug, used in
the proper setting at the proper dose for the proper amount of
time, it can be certainly--you don't want your patient to
suffer. So I think we need to find that little niche, and I
know it is hard. Individual patients take individual therapy,
but, you know, we don't need to throw the baby out with the
bathwater completely. We want to make sure that that troop,
that retiree does not suffer because we were scared to write a
prescription. We have got to do the right thing in a lot of
areas, and so hopefully we will get this right.
So thanks for what you guys are doing. Maybe we can use
this as a model for our civilian population.
So I yield back, Mr. Chairman.
Admiral Bono. Thank you, sir.
Mr. Coffman. Thank you, Dr. Abraham.
Ms. Rosen.
Ms. Rosen. Thank you, Mr. Chairman.
And thank you for being here today. I have a couple of
questions. One of my questions is about your prescribing, and
so I know--I am from a physician family. My husband is a
physician. Actually, he just had back surgery, and he has had a
little bit of experience in some of these prescription issues,
but are your models separating out inpatient drug use versus
outpatient drug use because there is major and minor
procedures. My husband had back surgery; major procedure,
requires different types of treatment than someone coming in.
So that is my first part of the question.
And then also, in regards with that inpatient to
outpatient, how are you working with emergency rooms, not in
our VA hospitals or in our treatment facilities but in the
general population, to be sure that people aren't drug shopping
by going to some other outpatient center?
Admiral Bono. Yes, ma'am. I will take the ED [emergency
department] one, and then I will let Captain Colston talk about
the difference of inpatient with outpatient because you are
right, there is a difference there. Part of our participation
with the PDMP allows us now to have full visibility of people
going to the ED for prescriptions and even pharmacy being able
to see these pharmacies that--the pharmacies that they attend
or go to to get their prescriptions filled. So we have a lot of
visibility now on what we are doing.
Our partnership with Express Scripts, since 63 percent of
our patients receive their care from--or receive their opioids
from civilian pharmacies or get the prescriptions from our
civilian partners, they have provided us complete visibility of
that, as well, and they report to us when we--when one of our
patients reaches a certain threshold of opioid prescriptions
or--and how much they are taking.
Ms. Rosen. And they do that across all types of
prescriptions because people can get multiple drugs----
Admiral Bono. Yes, ma'am.
Ms. Rosen [continuing]. That do the same effects.
Admiral Bono. Yes, ma'am. And as a matter of fact, part of
our training has raised the awareness of some of those other
multiple drugs, particularly benzodiazepines, and that is what
we have actually seen a slight decrease in our providers
avoiding prescribing benzodiazepines at the same time. So, yes,
exactly, we are tracking that very closely, and we have much
better visibility of that now.
As far as inpatient and outpatient, since Captain Colston
is actively taking care of both inpatient and outpatient, I
will let him--I think you were in outpatient, weren't you?
Captain Colston. Yes.
Ms. Rosen. Inpatient monitoring is different, and then you
have to worry about when they become an outpatient as they
transition, right?
Captain Colston. Yes, ma'am. So a few things about
inpatient care and major procedures. Of course we use opiates.
We use opiates surgically. We use them with other drugs. We use
them with ketamine drips. We use them with nerve blocks. We use
other pharmacological modalities to reduce the amount of opiate
exposure that someone needs. Now, after a major procedure, say,
a coronary artery bypass graft or something along those lines,
you get 10 days of opiates when you leave. That is an extremely
painful procedure, and you have got your sternum cracked in
two. And if you need another one, 7 days, but that is really at
the point where we really need to watch you closely. Because
the thing that creates addiction is, it is almost always
iatrogenic. Three-quarters of people who become addicted get it
from medical intervention. So it is very important for us to
watch you in those of situations.
And the two variables that matter most are the dose, the
amount of opiates that we gave you, and how long we gave them
to you. And an opiate use disorder is an extremely lethal thing
to have. The 20-year mortality for that is 40 to 60 percent. So
you give--you turn an 18-year-old into an opiate addict, that
person may not reach 40. So we always need to weigh the risks
and benefits when we start medicine, but opiates are part--
definitely part of the medical care suite and something that,
of course, we want to deliver humane care, and we want to get
to pain.
One of the big things that we struggled with as physicians
in the early 2000s is we just tried to get rid of pain no
matter what the price, and we really created a number of folks
who struggled and died.
Ms. Rosen. Right. Well, thank you.
I yield back my time. I appreciate your work.
Mr. Coffman. Ms. Shea-Porter.
Ms. Shea-Porter. Thank you, and thank you for being here. I
wanted to show you a picture of Daniel Keegan. Daniel Keegan
was from my district, and he died from substance use disorder.
And I wanted to tell you the story and ask you a couple of
questions about him in honor of him and his mother, who is
working very hard to let the country know that we have a
problem and we have to do something about it.
Daniel Keegan enlisted out of high school at the Dover
Recruiting Office in my district. All he wanted to do was to
serve his country. He was the type of recruit that we need many
more of. Incredibly smart. He scored an 800 on the verbal and
760 on math. He was well trained by our military. He was an
impressive soldier. He attended the University of New Hampshire
to further his military career. We have an All-Volunteer Force.
We need people like Dan to stand up and answer that call to
serve, as you well know.
While serving, Dan developed a substance use disorder. DOD
diagnosed him, was aware of his problem, but when he separated,
he did not receive any help getting into the VA system to
continue treating his substance use disorder. In the time
period after he separated, he struggled to get his comp and pen
[compensation and pension] exam, relapsed, and then he died
waiting for his appointment, which was not scheduled until
nearly 16 months after he separated.
His mother Stephanie shared his story with us. When he
separated, Dan was struggling with this and was not equipped to
navigate the VA system. Nobody offered him help. The DOD did
not offer any help at all, even though they knew he had this
problem. In Dan's words, he was a disposable soldier. We spent
a fortune training him, but when he got sick, DOD dropped him.
The VA bears some responsibility here, but it is clear from
listening to Stephanie that Dan felt that DOD failed him. Dan
loved the VA and wanted to help other veterans with their
illness so they could access treatment. He would have been an
incredible member of our community after separating from the
DOD, but he wasn't given the chance because DOD dropped the
ball. He was not connected to DOD or VA service in a way that
might have saved his life.
In your testimony, you talk about all of the data that DOD
has to identify at-risk patients. You have medical records that
should show when a service member is being treated for
substance use disorder. You also talk about coordinating care
with VA, but you do not mention anything about what you will do
to ensure separating service members get the health care that
they need. I strongly believe that there has to be a system in
place that ensures separating service members who are eligible
for VA care and need VA care have an appointment scheduled
before they separate from DOD. The command responsible for a
soldier when he or she is separating should also be held
responsible for making sure that soldiers are receiving the
health care that they need when separating. As I said, they
knew what his problem was.
Many separating service members are simply left in a
position to navigate that whole system themselves, and clearly,
he couldn't. So I would like to ask you to respond to the
following questions. What is DOD doing to ensure that there is
no delay in getting care for separating service members? Is
there any way that they talk to the VA or in some way make sure
that there is a handoff, that we don't just leave them outside
the door of the military? Can DOD employ case managers or
coordinate care and ensure that his appointment is waiting for
separating service members that are diagnosed either or are at
risk for substance use disorder? And can we continue offering
mental health care to separated service members when the
handoff of the VA does not go smoothly and the service member
is encountering significant delays in accessing VA care? I
thank you for listening and would like to hear your response.
Admiral Bono. Thank you very much for sharing that, and it
is very sobering to hear something like that when we have
missed the ball on that, or we have let somebody fall through
the cracks. We do have quite a few programs, and we recognize
that we needed to be able to help transitioning service members
from the DOD to the VA, and actually, we have fairly numerous
programs. I would like to be able to give you a more complete
answer, if I could, to give you the list of some of those
programs because I don't have them readily at my fingertips. So
I would like to take that for the record if I could.
But if I may speak from a very broad perspective, DOD and
VA have done some considerable partnering in recent years
because we recognize that many of our patients are of the same
continuum, and part of their care needs to transition from DOD
to VA. We have recently agreed with the VA to share the same
electronic health record so that we would be able to retrieve
that information, the clinical information that is so necessary
to understand how to make these handoffs happen more smoothly
so we don't create unnecessary gaps in their care.
We have also been working at very high levels between the
DEPSECDEF, Deputy Secretary of Defense, and the Secretary of
the VA to make sure that we are working on those strategic
objectives, those strategic imperatives that allow us to be
more seamless in their delivery of care. And then we also have
several working groups and subcommittees of the DOD and VA to
address several transition issues, whether it is health,
behavioral health, or even in some cases the ability to
transition from working in the DOD to working in the VA health
system.
So, if I could, I would like to take that for the record so
I can give you a much more comprehensive answer, but at a
general level, we are working much more closely with the VA.
[The information referred to was not available at the time
of printing.]
Ms. Shea-Porter. I appreciate that. So, if Dan was
discharged tomorrow, would that system work, the one you just
described?
Admiral Bono. Yes, ma'am. I think that what you have
described and how his process went, I would like to think that
what we have put in place would not have let that happen.
Ms. Shea-Porter. Okay. Thank you very much. I yield back.
Admiral Bono. Thank you, ma'am.
Mr. Coffman. Thanks. So we are going to do a second round.
My question is to Active Duty personnel who sustain some type
of injury or requires surgery where they are given opioids for
a limited period of time, and let's say that that Active Duty
individual is then returned--they are returned to their duty
station, whatever it is, so they are not medically discharged,
but severe enough to be given--to undergo a regimen of opioid
medications or treatment. So let's say that, because of that,
they have a problem and that they are seeking out opioids or
drugs to--that they became addicted at some degree. Through--so
what tracking programs does the military have now? Do we still
have--we have periodic urinalysis program, would that pick up
these--is that programmed to pick up the opioids? And at what
level does it pick it up at? I mean, if somebody is not--maybe
tell me what the threshold is, if somebody has done it within
so many hours, what is the threshold requirement that that test
could pick it up?
Admiral Bono. Yes, sir. I think in general terms, and I
will let Dr. Colston refer to the actual milliequivalents that
we have set the threshold, not only do we--not only do Active
Duty undergo routine screening and for those patients that we
have identified that are long-term opioid users, they are
actually put on a regular regimen of urine screening so that we
can monitor that.
Mr. Coffman. Okay.
Admiral Bono. The other thing is we have also expanded our
urine screening, urine drug screening, to include many more
substances recognizing that that is a risk.
Mr. Coffman. Okay.
Admiral Bono. But in terms of what the actual level, I
don't know if Captain Colston might be more familiar with that.
Captain Colston. Yes, sir. So there is the readiness
testing that we do is totally separate from medical testing
that we do.
Mr. Coffman. Okay.
Captain Colston. The readiness testing does have thresholds
between positive and negative tests. It is extremely accurate.
We have confirmatory testing, which uses very expensive linear
chromatography gas mass spectrometry equipment. That is
something that has nothing to do with health. And what we want
to do is we want to treat these folks. We want to get these
folks medication-assisted therapy. We want--if they still have
a pain disorder, we want to use for medication-assisted therapy
a drug that also addresses their addiction, like methadone or
buprenorphine, and we have any number of providers who are
qualified to give those drugs. In fact, we have a surfeit of
providers capable of giving those drugs.
We have a policy on the medical side that we do not want to
stigmatize any kind of addiction. We want folks to get treated,
and, in fact, at the partial hospitalization program where I
work, command is kind of kept away for a little while as we
focus on these folks because, in fact, relapse is part of
recovery for addiction, and it is such a dangerous addiction,
opiates, that we really need folks to almost live in a vacuum
away from command, and we have been doing that for 7 years
there, I think, with great success.
Mr. Coffman. So I think my point is, so if somebody
undergoes this regimen of treatment due to surgery or due to
some injury that they have sustained, they then--you have a
monitoring system for them postelection--postprescription or
whatever you want to call it, and so nobody is going to fly
under the radar from your perspective in terms of----
Captain Colston. Well, the point I was trying to make, sir,
is the readiness testing is not a way that we find people who
are addicted. If we identify that you have an opiate use
disorder, you are going to get regular urinalysis. You are
going to get pill counts. We are going to check you for
diversion. We are going to do any number of actions that help
you get sober.
Mr. Coffman. But the readiness test would indicate----
Admiral Bono. Yes, oh, yes.
Captain Colston. Yes, sir. I just want to add that
readiness testing, the number of positive opiate screens is
down 76 percent in the last 5 years. So we know that we are
headed in the right direction on that problem, sir.
Mr. Coffman. Okay. And then how long have we been screening
for opioids and the testing?
Captain Colston. Since the Nixon administration.
Mr. Coffman. A long time. Okay.
Ranking Member Speier.
Ms. Speier. Thank you.
Admiral Bono, you are embarking on an $81 million, 6-year
research collaboration. Can you describe your plans for the
research, what population you are going to conduct the research
on, and the extent to which you are going to implement your
conclusions if they prove--therapies that they prove effective
before the actual research is completed, or are you going to
wait the 6 years?
Admiral Bono. Yes, ma'am. So we have several ongoing
research collaboratives. One of the most robust ones is with
West Virginia and also with NIH. So what we do with both of
these collaboratives is we make sure that, as we see results
and they get validated--and this is the important part of the
research, is being able to address certain types of aspects of
opioid addiction and treatment. And once we get validation and
we know that it is effective, we try to put those into place
right away.
As a matter of fact, Captain Colston and I were just
remarking that, in the last several years since 2015, because
we have started seeing the results of some of this research, we
have been able to put in many of those practices and those
treatments that we have understood better because of the
research, and that has been happening in the last few years. So
I anticipate that as we continue this level of effort, that we
will be able to implement things much more quickly.
Ms. Speier. Yield back.
Mr. Coffman. Dr. Abraham, nothing? Ms. Shea-Porter.
Ms. Shea-Porter. I am good.
Ms. Speier. One more question, Mr. Chairman.
Mr. Coffman. Go ahead.
Ms. Speier. I read an article that suggests that the use of
marijuana reduces the amount of opioid usage in those areas
that have legalized marijuana. I realize the Federal Government
is not one of them, but I am curious if you have done any
research on that. It was ``Medicare Patients Use Fewer Opioids
with Medical Marijuana Laws,'' was the headline on this
particular article.
Admiral Bono. Yes, ma'am. We are always monitoring other
aspects of care and seeing if there is scientific evidence-
based data that would help support that. So we are monitoring
that. We don't necessarily do that research, but we monitor
everybody else's research.
Ms. Speier. And if, in the end, it is found to be helpful,
what do we do about it?
Admiral Bono. Well, I think that would be something----
Ms. Speier. I guess that is our job.
I yield back.
Admiral Bono. I was going to ask for help on that one.
Mr. Coffman. I think you would need it.
I wish to thank the witnesses for their enlightening
testimony this afternoon. There being no further business, the
subcommittee stands adjourned.
[Whereupon, at 5:32 p.m., the subcommittee was adjourned.]
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A P P E N D I X
June 20, 2018
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PREPARED STATEMENTS SUBMITTED FOR THE RECORD
June 20, 2018
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[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
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QUESTIONS SUBMITTED BY MEMBERS POST HEARING
June 20, 2018
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QUESTIONS SUBMITTED BY MS. TSONGAS
Ms. Tsongas. I was pleased to read in your written testimony about
the Department's work to establish a Prescription Drug Monitoring
program. How does the DOD plan on requiring military medical treatment
facilities across the country to utilize and share information through
this new PDMP--particularly in emergency situations?
Admiral Bono. The Department has issued a Prescription Drug
Monitoring Program (PDMP) Contract Modification to Express Scripts Inc.
to provide visibility to Schedule II-V controlled substances dispensed
within the Military Health System (MHS) to registered PDMP prescribers,
pharmacists and law enforcement in all other states. Scheduled
completion date is 31 Dec 2018. The DOD PDMP program is an adjunct to
the existing monitoring capabilities that now exist for providers at
our Military Treatment Facilities (MTF). Prescriptions filled at any of
the three points of service (mail, retail and MTFs) through TRICARE
which have been cost shared by TRICARE are collated and available for
query by MTF providers in real time. The DOD PDMP program will also
capture controlled substances that were dispensed when the beneficiary
paid cash. This will ensure a complete history is available to any
provider, both military and civilian, who is registered to use the PDMP
program. Once available, DOD will work towards incorporating
appropriate PDMP review as part of the MHS patient care work flow.
Ms. Tsongas. Admiral Bono, have you seen any issues or trends
involving service members seeking opioid pain relievers due to chronic
musculoskeletal pain caused, in part or in whole, by heavy personal
protective equipment? If so, how is the Department seeking to manage
this causal factor?
Admiral Bono. Musculoskeletal injuries are the number one medical
threat to readiness. However, the rates of opioid abuse and dependence
are below 1% among TRICARE beneficiaries, with a 56% decrease since
2016. Currently, there is no direct evidence of opioid seeking behavior
related to heavy personal protective equipment. DOD has taken action to
address pain management and opioid safety through a comprehensive,
holistic approach by providing intensive training, utilizing external
partnerships, and implementing policies to discourage opioid overuse.
The MHS is synchronizing pain care under a stepped care model, which
equips primary care providers to encourage self-care and provide pain
management to patients with a focus on non-pharmacologic therapies. Our
goal is to help patients manage their pain at the lowest care level
necessary and to teach them the skills necessary to move back down the
continuum of care with the stepped care model. The MHS has optimized
opioid safety through specific opioid prescribing guidance for acute
pain episodes and minor procedures as well as major procedures in the
uncomplicated patient. The MHS has increased the opioid safety patient
information availability at the point of care. The Opioid Risk and
Recommended Clinical Actions (ORRCA) report is a clinical decision
support tool that providers will use to promote recommendations based
on clinical practice guidelines into each patient's individualized care
plan.
Ms. Tsongas. How does the DOD plan on offering and tracking the
effectiveness of opioid alternative treatments for chronic pain?
Admiral Bono. We use a tool called Pain Assessment Screening Tool
and Outcomes Registry (PASTOR) in specialty clinics to assess the
efficacy of our complementary and integrative therapies for chronic
pain. PASTOR is based on the National Institutes of Health investment
in Patient-Reported Outcomes Measurement Information System (PROMIS)
and provides advanced analytics for assessing patient reported
outcomes. PASTOR utilizes evidence-based patient reported outcomes to
assess effectiveness of clinical and programmatic pain management
interventions at both the individual and population health levels.
Ms. Tsongas. Admiral Bono, does the DOD have a plan to address how
retired service members can obtain alternate forms of pain management
through TRICARE without these retirees having to pay out of pocket?
Admiral Bono. We agree that complementary and integrative pain
therapies, such as mindfulness, massage, yoga, chiropractic care, and
acupuncture are essential to managing pain in our healthcare system. We
are actively considering addition of complementary and integrative
therapies to the TRICARE benefit for provisional coverage. Acupuncture
and chiropractic care are currently under review. Acupuncturists
currently are not TRICARE-authorized providers. DHA is proceeding with
a rule-making to remove the regulatory exclusion of acupuncture and add
acupuncturists as authorized providers.
Ms. Tsongas. How is the DOD training its medical professionals on
the treatment of newborns suffering from opiate exposure? If that
training is already in place, what does it look like?
Admiral Bono. There is no formal DOD training in place at this
time. However, providers caring for neonates should be following and
delivering care in accordance with the American Academy of Pediatrics
(AAP) Policy on Neonatal Drug Withdrawal, which utilizes a clinical
scoring system to determine abstinence and potential need for drug
therapy. Also, the General Pediatric Content Specifications published
by the American Board of Pediatrics and utilized in the curricula of
all the DOD Pediatric Residencies lists neonatal abstinence syndromes
(i.e., how neonates respond to withdrawal of any substance) among the
required knowledge for preparation for the certifying examination and
practice in the care of neonates.
Ms. Tsongas. What lessons has DOD learned from the Department of
Veterans Affairs on opioid prescribing practices?
Admiral Bono. has adopted the MHS Stepped Care Model for Pain,
modeled on the Department of Veterans Affairs (VA) patient experience,
as the comprehensive model of pain management focusing on non-
pharmacologic pain treatments. DOD and VA also developed the Defense
and Veterans Pain Rating Scale as the standard for pain scale. DOD
continues to execute the Joint Pain Education Project in disseminating
a standardized DOD and VA pain management curriculum used in education
and training programs improving pain management competencies in the
combined federal clinical workforce. DOD is committed to continued
coordination and collaboration with VA regarding comprehensive pain
management and opioid safety.
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