[Joint House and Senate Hearing, 115 Congress]
[From the U.S. Government Publishing Office]
S. Hrg. 115-70
ECONOMIC ASPECTS OF THE OPIOID CRISIS
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HEARING
BEFORE THE
JOINT ECONOMIC COMMITTEE
CONGRESS OF THE UNITED STATES
ONE HUNDRED FIFTEENTH CONGRESS
FIRST SESSION
__________
JUNE 8, 2017
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JOINT ECONOMIC COMMITTEE
[Created pursuant to Sec. 5(a) of Public Law 304, 79th Congress]
HOUSE OF REPRESENTATIVES SENATE
Patrick J. Tiberi, Ohio, Chairman Mike Lee, Utah, Vice Chairman
Erik Paulsen, Minnesota Tom Cotton, Arkansas
David Schweikert, Arizona Ben Sasse, Nebraska
Barbara Comstock, Virginia Rob Portman, Ohio
Darin LaHood, Illinois Ted Cruz, Texas
Francis Rooney, Florida Bill Cassidy, M.D., Louisiana
Carolyn B. Maloney, New York Martin Heinrich, New Mexico,
John Delaney, Maryland Ranking
Alma S. Adams, Ph.D., North Amy Klobuchar, Minnesota
Carolina Gary C. Peters, Michigan
Donald S. Beyer, Jr., Virginia Margaret Wood Hassan, New
Hampshire
Whitney K. Daffner, Executive Director
Kimberly S. Corbin, Democratic Staff Director
C O N T E N T S
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Opening Statements of Members
Hon. Patrick J. Tiberi, Chairman, a U.S. Representative from Ohio 1
Hon. Martin Heinrich, Ranking Member, a U.S. Senator from New
Mexico......................................................... 3
Hon. Margaret Wood Hassan, a U.S. Senator from New Hampshire..... 4
Witnesses
Statement of Richard G. Frank, Margaret T. Morris Professor of
Health Economics, Department of Health Care Policy, Harvard
Medical School, Boston, MA..................................... 5
Statement of Lisa N. Sacco, Crime Policy Analyst, Congressional
Research Service, Library of Congress, Washington, DC.......... 7
Statement of Hon. Mike DeWine, Ohio Attorney General, Columbus,
OH............................................................. 9
Statement of Sir Angus Deaton, Laureate of the Nobel Prize in
Economic Sciences, Senior Scholar and the Dwight D. Eisenhower
Professor of Economics and International Affairs Emeritus,
Woodrow Wilson School of Public and International Affairs and
the Economics Department, Princeton University, Princeton, NJ.. 12
Submissions for the Record
Prepared statement of Hon. Patrick J. Tiberi, Chairman, a U.S.
Representative from Ohio....................................... 34
Prepared statement of Hon. Martin Heinrich, Ranking Member, a
U.S. Senator from New Mexico................................... 36
Prepared statement of Hon. Margaret Wood Hassan, a U.S. Senator
from New Hampshire............................................. 37
Prepared statement of Richard G. Frank, Margaret T. Morris
Professor of Health Economics, Department of Health Care
Policy, Harvard Medical School, Boston, MA..................... 38
Prepared statement of Lisa N. Sacco, Crime Policy Analyst,
Congressional Research Service, Library of Congress,
Washington, DC................................................. 48
Prepared statement of Hon. Mike DeWine, Ohio Attorney General,
Columbus, OH................................................... 55
Prepared statement of Sir Angus Deaton, Laureate of the Nobel
Prize in Economic Sciences, Senior Scholar and the Dwight D.
Eisenhower Professor of Economics and International Affairs
Emeritus, Woodrow Wilson School of Public and International
Affairs and the Economics Department, Princeton University,
Princeton, NJ.................................................. 87
Response from Richard G. Frank to Questions for the Record
Submitted by Senator Klobuchar................................. 91
Response from Richard G. Frank to Questions for the Record
Submitted by Senator Lee....................................... 91
Response from Richard G. Frank to Questions for the Record
Submitted by Senator Heinrich.................................. 91
Response from Lisa Sacco to Questions for the Record Submitted by
Senator Lee.................................................... 93
Response from Mike DeWine to Questions for the Record Submitted
by Senator Klobuchar........................................... 95
Response from Mike DeWine to Questions for the Record Submitted
by Senator Lee................................................. 95
Response from Sir Angus Deaton to Questions for the Record
Submitted by Senator Lee....................................... 97
ECONOMIC ASPECTS OF THE OPIOID CRISIS
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THURSDAY, JUNE 8, 2017
House of Representatives,
Joint Economic Committee,
Washington, DC.
The Committee met, pursuant to call, at 10:01 a.m., in Room
1100, Longworth House Office Building, Hon. Pat Tiberi,
Chairman, presiding.
Representatives present: Tiberi, Paulsen, Schweikert,
Comstock, LaHood, Delaney, and Beyer.
Senators present: Sasse, Portman, Heinrich, Klobuchar, and
Hassan.
Staff present: Louis Agnello, Breann Almos, Theodore Boll,
Doug Branch, Kim Corbin, Whitney Daffner, Barry Dexter, Connie
Foster, Martha Gimbel, Colleen Healy, Adam Hersh, Karin Hope,
Matt Kaido, Brooks Keefer, John Kohler, AJ McKeown, Victoria
Park, Jana Parsans, Russell Rhine, and Alex Schibuola.
OPENING STATEMENT OF HON. PATRICK J. TIBERI, CHAIRMAN, A U.S.
REPRESENTATIVE FROM OHIO
Representative Tiberi. Good morning, and welcome. I want to
welcome especially our ranking member, Senator Heinrich, and
our vice chairman, Senator Lee, as well as other members of the
committee who join me in expressing the importance of holding a
hearing on the threatening increase in opioid abuse. Drug abuse
has become rampant in America and may be the worst the country
has ever experienced.
It is devastating families, degrading communities, and
undermining several parts of our economy. For several states
and districts represented by members of this committee, the
problem is acute, as the map displayed shows. As figure 1
indicates, the crisis has a regional character. My hometown of
Columbus, Ohio, is part of the crisis' epicenter east of the
Mississippi.
Figure 2 shows the 2015 drug overdose death rates by State,
which range from 40 per 100,000 in West Virginia to 6 per
100,000 in Nebraska. The states represented by the members of
this committee, among the 10 highest rates, are highlighted in
red, including my home State of Ohio, which ranks third.
Drug markets, both legal and illegal, can be analyzed from
the demand and supply side. The exact reasons for the extent of
drug abuse are not clear at this point. With respect to demand,
a changing perception of pain as a health problem in the 1980s
by the World Health Organization in particular laid the ground
for more intensive treatment.
The labor market and the economy can have a major impact on
demand, although not necessarily in ways one might expect. Some
research shows less substance abuse when unemployment
increases, for instance, and while the prolonged downturns in
labor market and economic conditions are associated with
social, behavioral, and health problems, they do not
necessarily affect all groups in the same way or to the same
degree.
All of society is vulnerable to this epidemic. It is
compounding the economic distress that certain parts of the
country and segments of the population already have been
experiencing. Some areas of high employment tend to have higher
rates of substance abuse. The Economic Innovation Group, a
representative of which testified at our last hearing, ``The
Decline of Economic Opportunity: Causes and Consequences,''
developed an economic distress index consisting of several
economic indicators, a national map of which is shown alongside
the map of overdose deaths in the TV screens in figure 3. The
darker the red, the worse the distress. Striking correlations
are visible. But it is also apparent from figure 3 that some
economically distressed areas are not experiencing high
overdose death rates.
From a supply side, the particular locations where new,
potent drugs initially happened to be become most readily
available, and the path of geographic market expansion they
took, track a visible trail of destruction in figures 1 and 3.
Without question, new developments in the sourcing, cost of
production, potency, and retail delivery have moved the supply
of both legal and illegal addictive drugs substantially to the
right. Newly effective pain medication, OxyContin, introduced
in the 1990s, had initially unacknowledged addictive qualities
and was overprescribed.
So-called black tar heroin, which Senator Heinrich and I
were just talking about, more powerful and less expensive than
other kinds, expanded its market share just as OxyContin was
reduced in potency around the country.
The prescription drug explosion started in the Appalachian
part of my State and spread to parts of Kentucky and West
Virginia. Black tar heroin started in the Southwest and spread
westward but eventually also eastward, crossing the Mississippi
in 1998.
Illegally distributed variations and counterfeit forms of
prescription drugs like fentanyl can be poisonous and kill a
person even in small doses, some by mere contact with the skin,
as Attorney General DeWine informed me earlier this year. We
now face pure poisons masked as narcotics that are shipped
across our borders. Senator Portman and I introduced the STOP
Act, which aims to stop dangerous synthetic drugs from being
shipped through our own postal service, keeping them out of the
hands of drug traffickers in the United States. Half the
members of this committee have signed on as cosponsors in a
bipartisan way, and we should continue to build support for
this important legislation.
It would be a mistake to blame these drugs entirely for the
rise in mortality that some groups and regions are suffering.
There are other causes apparently emanating from long-term
challenges in the composition of the economy and skill
requirements.
Determining cause and effect is obviously critical to
reaching the right conclusions. Feedback effects often
complicate causality and make a clear understanding of major
causes that we are experiencing difficult. For example, does a
bad economy lead to drug abuse or does drug abuse to a bad
economy by lowering productivity, labor force participation,
and social cohesion? We will hear about the economic decline of
certain groups leading to despair and self-destructive
behavior; of damage drug abuse causes individuals, families,
and communities in all segments of society; and of developments
in the production and marketing of addictive drugs which have
made them more dangerous, affordable, and available.
I look forward to the statements of our witnesses.
I will now yield to the ranking member, who has another
hearing. Mr. Heinrich is recognized.
[The prepared statement of Chairman Tiberi appears in the
Submissions for the Record on page 34.]
OPENING STATEMENT OF HON. MARTIN HEINRICH, RANKING MEMBER, A
U.S. SENATOR FROM NEW MEXICO
Senator Heinrich. Thank you, Chairman Tiberi.
And thank you so much for holding this incredibly important
and timely hearing.
Thanks to our panel for being here today.
Addiction to both heroin and prescription opioid pain
relievers is a public health epidemic that is devastating
families and communities across our Nation.
Every day, 91 Americans die from opioid overdose. Over-
prescription is partially responsible for this epidemic. Since
1999, the amount of prescription opioids sold in the U.S.
nearly quadrupled, and so too has the number of overdose deaths
from opioids. The economic costs of that addiction are
incredible, totaling more than $80 billion in 2013, from
increased healthcare costs, higher rates of incarceration, and
lost productivity.
New Mexicans know all too well the devastation that heroin
and prescription opioids can wreak. For years without adequate
treatment resources, communities in New Mexico have suffered
through some of the highest rates of opioid and heroin
addiction and overdose deaths in the Nation. Rio Arriba County
has a drug overdose death rate of 81 per 100,000, five times
the national rate.
I am reminded of a young man named Josh from Espanola, who
I met at a roundtable I hosted last year in Rio Arriba County.
At 14, Josh became addicted to prescription opioids. Over time,
he moved to heroin. He stole from his family and his friends to
maintain his growing addiction. Josh spent time in jail where
he went through the pains of withdrawal. He even attempted
suicide.
Now in his 20s, Josh has turned his life around because he
finally got access to treatment and services. For millions of
Americans proven substance use treatment is available because
of, one, behavioral health parity laws and, two, the Medicaid
program. In New Mexico, Medicaid, called Centennial Care, is at
the forefront of our fight against the opioid crisis,
accounting for 30 percent of lifesaving medication-assisted
treatment payments for opioid and heroin addictions.
At exactly the time that Congress should be giving states
more tools to fight this epidemic, House Republicans passed a
bill that would repeal Medicaid expansion, artificially cap the
program, and shift the burden about who and what to cut onto
individual states.
More than a million people who have been able to secure
treatment for substance abuse would lose their coverage.
Repealing Medicaid expansion would cut about $4.5 billion from
treatment for mental health and substance abuse. We cannot
fight a public health crisis with grant dollars alone. Grant
dollars run out. Block grants lose their buying power over
time, and private investment dollars, which are critical in
this fight, won't come without certainty that the foundation is
funded.
Unfortunately, I will not be able to stay here to hear the
important testimony of our witnesses today because of a hearing
you may have heard about in the Intelligence Committee, but I
will be leaving you in the very capable hands of my colleague
Senator Hassan. New Hampshire loses at least one person every
day to a drug overdose. As Governor, Senator Hassan used every
tool at her disposal to fight the epidemic, including turning
to the flexibility of the Medicaid program to gain ground in
her State's fight. I will tell--I will let her tell you more,
but I leave you with this: When a community faces a public
health crisis, it is not long before a State turns to the
Medicaid program to stem the tide.
Thank you, Senator Hassan, I will turn over the rest of my
time to you.
And thank you, Mr. Chairman, for holding this critical
hearing.
[The prepared statement of Senator Heinrich appears in the
Submissions for the Record on page 36.]
OPENING STATEMENT OF HON. MARGARET WOOD HASSAN, A U.S. SENATOR
FROM NEW HAMPSHIRE
Senator Hassan. Well, thank you, Mr. Chairman and Ranking
Member Heinrich.
And to our witnesses today, thank you for being here as
well.
As I travel across my home State of New Hampshire, I hear
from countless families and those on the front lines about how
the heroin, fentanyl, and opioid crisis has devastated
communities across our State. And I know that many of our
colleagues have heard of the impacts in their states as well.
I am proud that, during my time as Governor, Republicans
and Democrats in New Hampshire put our differences aside and
came together to pass and reauthorize our State's bipartisan
Medicaid expansion plan. Medicaid expansion is providing
quality affordable health coverage to more than 50,000 Granite
Staters, including coverage for behavioral health and substance
use disorder treatment. Experts have said it is the number one
tool we have to fight this crisis.
We should be coming together here, just as we did in my
home State, to support those on the front lines and help those
who are struggling with addiction. And while members of both
parties and the administration have discussed the severity of
this crisis, we need these words to be matched by action. What
we cannot do, however, is end Medicaid expansion and institute
deep and irresponsible cuts to the traditional Medicaid
program.
This crisis is a public health and law enforcement issue,
but it is also an economic one. I believe the investments in
helping people recover are a far better use of our dollars than
the long-term cost of addiction, both in terms of State budgets
but also in ensuring that individuals are healthy enough to
contribute to the economy.
I am pleased that we are having this hearing today and very
grateful to the chair for calling it, but we need to continue
to hold hearings on how proposals made here in Washington would
affect our ability to stem and ultimately reverse the tide of
this epidemic. This is an issue that rises above partisanship,
and this is the work that we need to be doing because the lives
of our people in our states depend on it.
I am going to continue to work with my colleagues on
solutions, while standing firm against any policy that will
pull us backwards. With that, I thank you, and I look forward
to hearing from our witnesses.
[The prepared statement of Senator Hassan appears in the
Submissions for the Record on page 37.]
Representative Tiberi. Thank you.
Let me introduce our first witness. Richard G. Frank is the
Margaret T. Morris Professor of Health Economics at the
Department of Healthcare Policy at Harvard University Medical
School. He has held several positions at the Department of
Health and Human Services. Most recently, he served as the
Assistant Secretary for Planning and Evaluation.
Dr. Frank served as an editor for the Journal of Health
Economics. He is the recipient of awards from the Southern
Economic Association and the American Public Health Association
and others, and he is the coauthor of the book ``Better But Not
Well.''
Dr. Frank, you are recognized for 5 minutes.
STATEMENT OF RICHARD G. FRANK, MARGARET T. MORRIS PROFESSOR OF
HEALTH ECONOMICS, DEPARTMENT OF HEALTH CARE POLICY, HARVARD
MEDICAL SCHOOL, BOSTON, MA
Dr. Frank. Good morning, Chairman Tiberi and Senator
Hassan. Thank you for inviting me to participate in this
discussion of the opioid epidemic that is plaguing our Nation.
Just over 33,000 people died in 2015 from opioid overdoses. In
the time I have with you today, I want to focus on the gap
between the need for treatment and the receipt of care.
In 2015, there was an estimated 2.66 million people with an
opioid use disorder in the country. The illness is concentrated
in the low-income population. That is, 51 percent of people
with an opioid use disorder, or OUD, have incomes below 200
percent of the Federal poverty line. Only 26 percent of the
people with an OUD receive treatment for that disorder. That
means that 1.97 million people who needed care did not get it.
This is tragic because they are treatments that work.
Medication-assisted treatment has been shown to be the most
effective treatment for OUDs. They are combinations of
pharmaceuticals, psychotherapy or counseling, and drug testing
to monitor treatment adherence.
Now, national survey data show that over half the people
that did not get treatment because they either couldn't afford
it or there were no providers available. Other reasons for not
getting care were not being ready to stop using substance,
stigma, and the denial of the problem.
Now, policy tools are most amenable for addressing the
affordability and availability reasons. I will focus on three
areas that are helping to make the treatment gap smaller: They
are Medicaid, private insurance, and Federal grants.
Medicaid covers about 34 percent of people with an OUD.
Recent policy changes in Medicaid have bolstered Medicaid's
impact. The combination of the Mental Health Parity and
Addiction Equity Act that requires comparable coverage for
mental health and substance abuse disorders with medical
surgical care, the Medicaid expansions, and the essential
health benefit that includes substance abuse treatment all have
driven Medicaid to a growing role. Together, these provisions
have resulted in large increases in the use of medication-
assisted treatment.
A number of states have been using Medicaid as a central
part of their attack on the opioid epidemic. The State of Ohio
recently reported substantial increases in access to care for
people with opioid use disorder. And in Ohio, Medicaid now pays
for nearly half of all the buprenorphine prescriptions in that
State, which is one of the key drugs in medication-assisted
treatment.
Let me now turn to private insurance. Private insurance
covers about 42 percent of people with an opioid use disorder.
Recent changes there have bolstered the ability of private
insurance to shrink the treatment gap. They are the Parity Act
applied to private insurance, the essential health benefit
provisions in the small group and individual market, and the
availability of subsidized insurance policies for low income.
In 2011, a survey of individual market insurers revealed
that 34 percent of policies sold did not cover substance use
disorders. Today that is no longer the case.
Finally, grants to states. The recently enacted 21st
Century Cures Act appropriated $1 billion over 2 years that was
intended to focus on closing the treatment gap by expanding
capacity and expanding direct treatment. Just under $500
million of that money has been recently allocated to the
states.
Let me take a moment to put the Cures money into context
using the State of Kentucky's experience. Kentucky is receiving
a grant of about $10.5 million under Cures. That buys about
1,900 full-year treatments with medication-assisted treatment.
Currently, Medicaid pays for 4,200 person years of treatment in
Kentucky, and three-quarters of that is for the expansion
population. That means if Medicaid cuts at the magnitude
proposed occur, the Cures funds would likely not be used to
expand capacity and treatment, but would instead backfill for
Medicaid losses and wouldn't even be able to cover two-thirds
of those.
I now touch on availability. Since policy changes that I
have described have begun, there has been a surge of new
private money into this sector. There have been 170 private
equity deals between 2012 and 2015, some as large as $100
million. These private investments are aimed at scaling up
evidence-based practices, and the investment community
acknowledges it is directly linked to the flow of new funds,
both on the private and the public sides.
So the last 10 years have brought--have set a platform for
closing the treatment gap. The evidence suggests we are
starting to see important expansions in both capacity and
treatment that will pay dividends in the future. Turning back
now doesn't make economic sense and likely leads to tragic
consequences. Thank you.
[The prepared statement of Dr. Frank appears in the
Submissions for the Record on page 38.]
Representative Tiberi. Thank you, Dr. Frank, for your
testimony.
Our next witness, Dr. Lisa Sacco, has been an analyst in
crime policy with the Congressional Research Service since
2011. The past 5 years with CRS, she has specialized and
published reports on domestic drug enforcement, synthetic
drugs, prescription drug abuse, and various other drug and
crime policy issues.
Prior to working at CRS, she received her doctorate in
criminology and criminal justice from the University at Albany,
held several drug-related research positions, and taught
college courses on drugs and crime.
Dr. Sacco, welcome. You are recognized for 5 minutes.
STATEMENT OF LISA N. SACCO, CRIME POLICY ANALYST, CONGRESSIONAL
RESEARCH SERVICE, LIBRARY OF CONGRESS, WASHINGTON, DC
Dr. Sacco. Thank you.
Chairman Tiberi, Senator Hassan, and distinguished members
of the committee, my name is Lisa Sacco, and I am a CRS crime
policy analyst. Thank you very much for inviting me to speak
with you. My testimony will focus on the scope of the supply of
opioids in the United States. I will begin by stating three
points from my written testimony that I will expand upon today.
First, heroin, fentanyl, and controlled prescription drugs
have been ranked as the most significant drug threats to the
United States. While the reported availability of controlled
prescription drugs has declined over the last several years,
the reported availability of heroin and illicit fentanyl has
increased. The availability of these drugs is a contributing
factor to rising consumption. Second, the supply of opioids
varies by region of the United States. Third, while the Federal
Government has generally concentrated on reducing the supply of
illicit drugs, Federal drug control funding for supply
reduction has remained relatively flat over the last several
years while funding for demand reduction has increased.
While opioids have a long history in the U.S., this
testimony focuses on the last several decades, as the market
for these drugs has shifted a great deal. In the 1990s,
availability of prescription opioids increased as the
legitimate production of these drugs and ensuing diversion from
lawful use increased sharply. This continued into the early
2000s as users obtained their prescription drugs through means
such as doctor shopping, pill mills, the internet, and through
family and friends.
The Federal Government and State and local governments
undertook a range of approaches to reduce the unlawful
prescription drug supply, including diversion control through
prescription drug monitoring programs, the crackdown on pill
mills, the increased regulation of internet pharmacies in 2008,
the reformulation of OxyContin in 2010, and the rescheduling of
hydrocodone in 2014.
Some experts have highlighted a connection between the
crackdown on the unlawful supply of prescription drugs and the
subsequent rise in heroin supply and abuse. Heroin is a cheaper
alternative to prescription drugs that is often more accessible
to some who are seeking an opioid high. While most users of
prescription drugs will not go on to use heroin, accessibility
and price are central factors cited by drug treatment patients
in their decision to turn to heroin.
The trajectory for heroin supply over the last several
decades is much different compared to prescription opioids, but
the stories of their supply are connected. In the late 1990s
and early 2000s, white powder heroin produced in South America
dominated the market east of the Mississippi River, and cheaper
black tar and brown powder heroin produced in Mexico dominated
the market west of the Mississippi.
Price and purity varied considerably by region. In 2000,
most of the heroin seized was from South America while a
smaller percentage was from Mexico. In recent years, this has
dramatically changed. Over the last several years, heroin
prices have declined while purity, in particular the purity of
Mexican heroin, has increased. Over 90 percent of the heroin in
the U.S. seized is from Mexico, and a much smaller portion is
from South America. Mexican traffickers dominate the U.S.
market because of their proximity to the U.S., their
established transportation and distribution infrastructure, and
their ability to satisfy U.S. heroin demand. Increases in
Mexican heroin production have ensured a reliable supply of
low-cost heroin, even as demand for these drugs has increased.
Mexican traffickers have increased their production of white
powder heroin and may be targeting those who abuse prescription
opioids.
Compounding the current opioid problem is a rise of non-
pharmaceutical fentanyl on the black market. Fentanyl is often
mixed with or sold as heroin, and it is 50 to 100 times more
potent than heroin. Non-pharmaceutical fentanyl largely comes
from China and is reportedly cheaper than the cost of heroin.
The increased potency of synthetic fentanyl compounds is
extremely dangerous, and law enforcement expects that the
fentanyl market will continue to expand in the future as new
fentanyl products attract additional users.
The threat posed by opioids has increased since 2007, and
the threat varies by region. In 2016, approximately 45 percent
of law enforcement agencies that responded to the National Drug
Threat Survey reported heroin as the greatest threat in their
area. In contrast, 8 percent of respondents reported heroin as
the greatest threat in 2007. Reports of heroin as the greatest
threat are concentrated in the Northeast, Midwest, and mid-
Atlantic regions.
Opioids are the main cause of drug overdose deaths. Reports
indicate that increases in overdose deaths are most likely
driven by fentanyl and heroin. The increasing availability of
heroin and other opioids throughout the U.S., largely, but not
entirely, corresponds to the increases in drug overdose deaths
around the country. For example, New Hampshire ranks second in
the country in drug overdose deaths, and they have reported
high availability of heroin in the area. New Mexico and Utah,
on the other hand, rank eighth and ninth, respectively, but
only 4.7 percent of survey respondents in the Southwest
reported heroin as the greatest threat, and 22.6 percent
reported high availability of the heroin. This discrepancy may
be explained by a number of factors, including lethality of
fentanyl.
Historically, the Federal Government has concentrated on
reducing the supply of illicit drugs, but in recent years,
efforts to reduce the demand for these drugs have increased.
Federal drug control dollars largely go toward addressing the
supply side. However, Federal drug control funding for supply
reduction has remained relatively flat over the last several
years while funding for drug treatment and prevention has
increased. Thank you.
[The prepared statement of Dr. Sacco appears in the
Submissions for the Record on page 48.]
Representative Tiberi. Dr. Sacco, thank you for your
testimony.
It is an honor to introduce my attorney general, Senator
Portman's attorney general, Mike DeWine, who has served as a
State senator in Ohio, as a Member of the United States House
of Representatives, as a U.S. Senator, and now as Ohio's 50th
Attorney General. Your tough--Ohio's tough drunk driving law
has been a leading proponent for highway safety and has
advocated for victims of crime.
He has assisted local law enforcement, advanced the use of
DNA evidence for victims of crime, made efforts to assure
prescriptions are safe, and worked tirelessly to fight the
opioid epidemic in our State. I have known Mike for decades. I
am pleased you were able to come today to testify and give us
your thoughts.
You are recognized for 5 minutes.
STATEMENT OF HON. MIKE DeWINE, OHIO ATTORNEY GENERAL, COLUMBUS,
OH
Attorney General DeWine. Chairman Tiberi, Senator Hassan,
and members of the committee, thank you so much for inviting me
today.
The most visible sign of opioid epidemic in Ohio, of
course, is the number of deaths that we have. Last year, the
official total was eight per day. I think it was, frankly, more
than that. Today, at least, it is clear that that number is
going up.
But the cost is so much more. Every day, in Ohio, we have
babies who are born who are addicted. We don't know what the
developmental cost for each of those children will be, what
that will impact that particular child, but we know that many
of them will in fact be impacted. We do know what the cost is.
The cost in the hospital neonatal intensive care unit, the
average child there I think spends about 14 days there at very
tremendous cost.
Our foster care system is bursting at the seams; our
children services are. Fifty percent of all the foster care
children--people--children who are in foster care are there
because one or both parents are drug addicts. Seventy percent
of the infants that are in foster care are there because one or
both parents are drug addicts.
Our jails in Ohio are overflowing. We have more women in
our jails and our prison system than we ever had by far to
date. Our jails in Ohio in our 88 counties are really detox
centers, something that they were not really designed for at
all.
Narcan. All responders carry Narcan. As we move in that--it
is a great thing, and we have advocated for that, but as we
move from pain meds to heroin to fentanyl to carfentanil, it
takes more and more dosages. I had an officer tell me the other
day that it took 12 different dosages to bring someone back to
life.
But the number--the big cost that we really--I think it is
much more difficult to determine, but it is huge, absolutely
huge--is the number of people who are in Ohio who cannot pass a
drug test and, therefore, cannot have a number of jobs. You
could never hire someone who can't pass a drug test to be
around machinery. Never hire someone to even be in charge of
the local McDonald's or the Burger King. You cannot have
someone to drive a truck.
The missed opportunities, the fact that these people are
not living up to their God-given potential with the tremendous
impact it has on their own family but also the impact it has on
the State of Ohio is just absolutely huge. I do kind of a
little quiz when I talk to employers, and I say, ``Do you drug
test?'' If they say, ``Yes, I drug test,'' I say, ``Well, what
percent of the people who come in here--and you tell them they
have to take a drug test--leave before they take the drug test
and then add to that the percentage of people who come in here
and are so arrogant or stupid or both that they take the test
and fail it?'' The average that comes back when you put those
two numbers together almost every single time is 40 percent. It
is not scientific. It is anecdotal. But it tells us, I think,
some of the great loss we have.
What do we do about it? We start, I think, with the premise
that most people who are addicted today of heroin, fentanyl, et
cetera, started with pain meds. The first thing that we did is
we took the licenses of over 100 doctors in the State of Ohio.
These were bad people. These were drug dealers. They needed to
go away.
But what remains is a lot of good doctors who are still,
frankly, influenced by a culture that we believe the evidence
shows was caused by the drug companies purposely to indicate
that someone who has long-time chronic pain that is not
terminal, that they are an appropriate candidate for pain meds.
These doctors still, I think, some believe that pain meds are
appropriate for that circumstance. I think that is a problem.
We are slowly changing that culture, Mr. Chairman, and I think
making improvement.
Local communities must own the problem. There must be an
admission that there is in fact a problem. What follows that
should be an inventory. What are the assets that we have? What
are the challenges that we face? And then all the community has
to go together. The business community, the law enforcement,
the educators, and the churches. One of the things we have
emphasized in our office is the faith-based community needs to
be involved.
Another thing that is happening in Ohio, Mr. Chairman, is
law enforcement is doing something it never did before, and
that is helping get people into treatment. Just amazing
stories. Senator Tharp--excuse me, I gave him an increase in
title. Sheriff Tharp in Lucas County does an amazing job. They
go to the emergency room. They take people from the emergency
room if they are ready for treatment, and they work with them
and get them into treatment.
Let me talk about two other things, if I could, Mr.
Chairman, and then I will conclude. I believe that we need to
move to a K through 12, every year, talking about--to kids in
school about this problem. I think it should be repetitive,
comprehensive, and school-based. And it must be age
appropriate. You are not going to talk to kindergarten kids
about heroin, but you will talk to them about maybe good
choices and health. And if you see a pill, don't pick that up.
I was on Reagan's National Commission on Drug Free Schools.
Every expert who came in said you have to start in
kindergarten; you have to do something every single year. We
had a study commission that put this out, and I would make this
available to anyone who is watching this or any members of the
committee, it is on 23 or 24 page. We have mailed this to every
superintendent in the State.
Finally, Mr. Chairman, I think in this country we need to
do something. And I think it really needs to be on a national
scale. We have to change the culture. When I was a county
prosecuting attorney in the 1970s, heroin was something that
even people who were doing drugs, most people wouldn't touch
heroin. There was a psychological barrier there. That barrier
is simply gone today and no longer exists.
I think what we need is a media blitz, a social media blitz
on TV that is aimed at really two people--two groups of people.
One are kids, and one are parents and adults. Get all the
experts together. I am not an expert in this, but put them
together, put the best media people we can put together, and
let's try to change the culture. Because the irony is that as
we have changed the culture in regard to tobacco--it took a
long time; we have gone in the right direction--in regard to
opiates, we have gone in absolutely the opposite direction. We
can turn this around.
Thank you, Mr. Chairman.
[The prepared statement of Attorney General DeWine appears
in the Submissions for the Record on page 55.]
Representative Tiberi. Thank you.
Our last witness is Professor Sir Angus Deaton, who is a
senior scholar and Dwight D. Eisenhower Professor of Economics
in International Affairs Emeritus at Princeton University's
Woodrow Wilson School. He is also Presidential Professor of
Economics at the University of Southern California. He is a
member of the National Academy of Sciences, the American
Philosophical Society, and an Honorary Fellow of the Royal
Society of Edinburgh. He was president of the American Economic
Association in 2009.
In 2015, he received the Nobel Prize in Economic Sciences.
In 2016, he was knighted by Prince William at a Buckingham
Palace ceremony.
Thank you for joining us today, Professor Sir Angus Deaton.
You are recognized for 5 minutes.
STATEMENT OF SIR ANGUS DEATON, LAUREATE OF THE NOBEL PRIZE IN
ECONOMIC SCIENCES, SENIOR SCHOLAR AND THE DWIGHT D. EISENHOWER
PROFESSOR OF ECONOMICS AND INTERNATIONAL AFFAIRS EMERITUS,
WOODROW WILSON SCHOOL OF PUBLIC AND INTERNATIONAL AFFAIRS AND
THE ECONOMICS DEPARTMENT, PRINCETON UNIVERSITY, PRINCETON, NJ
Professor Deaton. Thank you, Chairman Tiberi, Senator
Hassan, and the other members of the committee for holding this
hearing on economics and the opioid crisis.
Deaths from legal and illegal drugs are contributing to an
almost unprecedented increase in overall mortality among
middle-aged white non-Hispanics. A century of mortality decline
came to a halt at the end of the 20th century, and mortality
rates for this mid-aged group were higher in 2015 than in 1998.
Driven by these developments, life expectancy at birth, a key
indicator of how well a society is doing, fell for white non-
Hispanics from 2013 to 2014, and for the whole population of
the United States from 2014 to 2015.
Opioids are a big part of the story. Supplies of opioids
have stoked and maintained the epidemic. Selling heroin is
profitable and illegal. Selling prescription drugs is
profitable and legal. Pharmaceutical companies have made
billions of dollars in profits on prescription opioids.
Opioids have a legitimate, if limited, role in treating
pain, but perhaps it would have been better had they never been
approved. Physicians are far from infallible in detecting which
patients are likely to become addicted, and once patients are
addicted, treatment is difficult and often unsuccessful.
My work with Anne Case has examined opioid deaths as part
of an epidemic of mortality, what we call deaths of despair.
These are suicides, deaths from alcoholic liver disease and
accidental overdoses from legal and illegal drugs. The opioid
deaths are the largest component. In 2015, for white non-
Hispanic men and women aged 50 to 54 without a college degree,
who were much more seriously at risk than those with a college
degree, deaths of despair are around 110 per 100,000, of which
50 are accidental overdoses, 30 are suicides, and 30 are from
alcoholic liver disease and cirrhosis.
There has recently been turn-up in mortality heart disease
after many years of decline. And if obesity is the cause, some
of these deaths might be deaths of despair, which would put a
total at levels approaching deaths from cancer or from heart
disease, the two major killers in midlife.
Figure 1 shows the all-cause mortality rate for white non-
Hispanics, the red line aged 45 to 54, together with mortality
rates for selected comparison countries. The mortality rates in
midlife in other countries continued to decline at the rates
that prevailed in the United States before 1998.
Americans are killing themselves by drinking, by
accidentally overdosing, by overeating, or, more quickly and
more straightforwardly, by committing suicide.
Deaths of despair have risen in parallel for men and women,
see figure 2. Such deaths, like all suicides, are lower for
women than for men, but the increases have marched in lockstep.
The key distinction here is not between men and women, but
rather between those with and without a college degree.
Deaths of despair cannot be explained by the economy. They
were increasing before the Great Recession and continue to
increase afterwards.
We think of all of these deaths as suicides of a kind, and
suicides respond more to prolonged economic conditions and to
the associated social dysfunctions and loss of meaning in the
interconnected worlds of work and family life.
Workers who entered the labor market before the early
1970s, even without a college degree, could find good jobs in
manufacturing, jobs that came with benefits and on-the-job
training, that could be expected to last, and that brought
regular increases in earnings, and a road to middle class
prosperity. Not so today.
With fewer good jobs, there has been a decline in marriage
rates, though couples often cohabit and have children out of
wedlock. Those cohabiting relationships are less stable than
marriages so that many fathers do not live with or even know
their children, and many children have lived with several
``fathers'' by their early teens, ``fathers'' in quotes.
Heavy drinking, overeating, social isolation, drugs, and
suicide are plausible outcomes of these processes that have
cumulatively undermined the meaning of life for white working
class people. Within this context, we tend to see the opioid
epidemic as an accelerant, as something that has poured fuel on
the fire of something that was already very bad already. Thank
you very much.
[The prepared statement of Professor Deaton appears in the
Submissions for the Record on page 87.]
Representative Tiberi. I would like to thank you all for
your testimony today.
Before I begin asking my questions, just two notes. In the
spirit of bipartisanship, I allowed the Democratic witness to
go first. I hope that is noted, as we move forward and continue
bipartisanship on this panel. And I allowed the former Senator
and former Member of this body, House, a little few extra
minutes out of professional courtesy.
With that, Mr. Attorney General, you hit on something in
your testimony that I hear about all the time in the seven
counties in my district, whether it be urban, suburban, rural,
or small town, and that is the impact that this is having on
the economy, employers who are saying: You know, I have three
positions open and I can't find anybody to fill the position
who can pass a drug test.
From your perspective and all the work that you have done
in this area, whether it is heroin or opioids or whatever type
of drug abuse, where do you see in our State, the problem being
the worst in terms of the economic conditions? Is it places
that have historically been left behind? Does geography not
make a difference? Can you give us your thoughts on it?
Attorney General DeWine. Mr. Chairman, I think if we
analyze this, what is different about this drug problem that we
have is how pervasive it is. It is absolutely everywhere: It is
in our smallest communities. It is in our cities. It is in our
most affluent suburbs.
I think if you go back historically, you could trace the
beginnings of this to southern Ohio or Appalachian counties in
regard to the pain med problem. We think that most of the
addiction, although some people may start on heroin, most
people become addicted to the pain meds, and they move to the
heroin because, at some point, they can't get the pain med
anymore and because heroin is so cheap. They move then possibly
to fentanyl and carfentanil. So, if you go back 10 years, where
you would see--where the biggest problem would be is in
southern Ohio with the pain med problem.
I am not a sociologist. I am not sure I can--I can guess,
but I don't have a great deal of expertise in this area at all,
but it starts with that. But it is absolutely everywhere.
And part of the challenge, I think, always, as you look at
this problem, and I know that some states are at a different
stage than we are--we are well down the path--what I would
suggest is the biggest challenge you have is getting people to
understand that this is a problem in their community. Their
community. And for the last 5 years, every interview I have
done on this, I have looked into the camera, if it was a TV
camera, and I have said: If you are watching this, you have an
opioid problem, you have a drug problem in your community.
Representative Tiberi. So just one followup, you mentioned
a demand problem and talking to kids as early as kindergarten.
How about the supply problem? Is there any way to deal with
that? You said you see it everywhere in our State; law
enforcement is seeing it everywhere. Any thoughts on the supply
issue?
Attorney General DeWine. Well, of course, you are talking
to somebody who was a county prosecuting attorney. And what we
do in the Attorney General's Office is assist local law
enforcement. So we always look first to the law enforcement
problem. And what we did 5 years ago is we created what we call
the Law Enforcement Heroin Group--Unit out of BCI, and I can't
really talk in public about exactly what we do, but we will go
in and help the local sheriff or the local prosecutor or the
local police. Once they have already started their drug
investigation, we will help them take it to a higher level and
to get the bigger fish and the bigger drug dealers. That
remains an essential part of what we do.
I have talked to the Attorney General of the United States
about cooperation with information coming off the border, and
that is a work in progress, so that we get real-time
information coming off the border back into Ohio. So we do work
with our Federal partners and the FBI, Drug Enforcement
Administration, and we have a very close and good working
relationship with them.
So law enforcement is a key component part, but we are not
going to arrest our way out of this problem. We have to deal
with it holistically, which is do a better job in regard to
treatment and getting people into treatment and keeping them in
treatment. And we have to do a better job, a much better job,
with prevention, which--where I think is the most opportunity.
If you look at this from the long run, where are we going to be
in 10 years, 15 years, 20 years? Start today in kindergarten,
and very few schools are doing this.
Representative Tiberi. Thank you.
Professor Deaton, you talked about the deaths of despair,
the economic conditions that cause it. Are those economic
conditions, from your perspective, getting worse or trending
better, or is it geographically different?
Professor Deaton. I think they have gotten somewhat better
in the short run, but I don't think of this as being a short-
run problem. I think this is a deep problem to do with, you
know, what people who don't have a university degree are going
to do with their lives. And the world that they used to inhabit
is a world that is broken. And I think the meaning--the things
that gave meaning to their lives, the steady jobs, are really
not there anymore. And I am not particularly optimistic.
I don't think it is a good idea for everyone to go to
college. I mean, I just think maybe things like apprenticeships
may be a new way of thinking about that world of work really
would help. I should say, though, that I de-emphasized the
opioids because that was my shtick here. But I think doing
something about the opioids in some sense is the easy part of
this, though, God knows it is hard enough and that we really
have to do that. We really have to change this culture of
doctors that believes that pain should be treated with heroin,
essentially, which is something we never used to do.
Representative Tiberi. Thank you, Professor. I appreciate
that.
My time has expired.
Ms. Hassan is recognized for 5 minutes.
Senator Hassan. Thank you very much, Mr. Chair.
And, again, thank you all for your testimony.
Dr. Frank, Medicaid has served as a lifeline for states
that have been hit hardest by the opioid epidemic, and experts
have said it is the number one tool we have in combating this
crisis. As a former Governor, I certainly understand how
critical it has been in ensuring that Granite Staters
struggling with addiction have access to treatment and recovery
services.
So I am obviously concerned that the Republican bill that
passed out of the House in May would fundamentally change the
Medicaid program as we know it. Instead of being a guaranteed
benefit for states and their residents, the per capita cap in
the plan would result in massive cuts that would set limits on
Federal contributions regardless of the need for care and
services. That will mean less buying power over time and leave
states with far fewer resources to provide services to their
citizens.
Could you address how a per capita cap approach to Medicaid
would impact a State's ability to fight this epidemic and/or
future public health emergencies?
Dr. Frank. Sure. Thank you for that question. The per
capita cap essentially is set up so that it locks in 2016 per
capita spending patterns and then inflates them forward at what
the Congressional Budget Office predicts is about 3.7 percent,
which is the expected consumer price medical component. And so
what that does is it allows you to keep up with general
inflation based on the 2016 patterns of treatment.
Now, as we know, mortality from opioids is growing at 15
percent a year; hospital admissions at about 6 percent; drug
treatments for opioid addiction is growing at 10 to 12 percent
a year. And so what happens is, when you have a per capita cap
that is based on that 2016 pattern and new things happen or old
things grow faster, you start to fall behind very quickly.
Senator Hassan. Thank you.
Dr. Sacco, we know, to your point, that we need to attack
the supply side of this epidemic, something that we have been
working on in New Hampshire. And we know how law enforcement
plays a critical role in cutting off supply side of illegal
opioids and other drugs into our communities. But in New
Hampshire, our law enforcement officials will be the first to
say, just as Attorney General DeWine just did, that we can't
arrest our way out of this problem. I still remember the
colonel of my State Police calling me when I was a new Governor
and saying, could I testify in favor of Medicaid expansion,
because we need it?
So we need to treat this as the public health crisis that
it is, and focus on addressing the demand side, which means
having an effective public health response that could be more
cost efficient and effective. Oftentimes, Medicaid--medication-
assisted treatment is less costly than simply incarcerating
someone with a substance use disorder, not to mention, being
more effective at addressing the problem and reducing
recidivism.
Dr. Sacco, do you agree that the opioid epidemic requires
both public health and law enforcement responses to address in
the crisis? Do you agree with the law official--the law
enforcement officials in my State and the attorney general here
that we can't simply arrest our way out of the problem?
Dr. Sacco. Senator Hassan, if you are seeking to address
both the supply and the demand, then, yes, there should be a
comprehensive approach. Generally, law enforcement addresses
the supply issue. Right now, the response seems to be one that
is comprehensive.
Senator Hassan. And would you agree that working on
expanding prevention, treatment, and recovery programs,
including Medicaid, is important to helping address the entire
crisis?
Dr. Sacco. CRS does not take a position on the advisability
of that. I am sorry.
Senator Hassan. Okay.
Dr. Frank, proposals coming out of the House would
undermine the essential health benefits of the ACA that
requires the coverage of substance use disorder services. CBO
says that that could increase out-of-pocket costs by thousands
of dollars.
Do you believe eliminating substance use treatment places a
barrier to access to care for people struggling with substance
use disorders?
Dr. Frank. Absolutely. We have seen in the states, for
example, that expanded Medicaid and in states where there has
been dramatic decreases in the uninsured rate from private
insurance, we see those are the states that have responded most
strongly with medication-assisted treatment in serving people
with opioid use disorders.
Senator Hassan. Thank you very much.
And I see my time is up.
Representative Tiberi. The gentleman from Minnesota is
recognized for 5 minutes.
Representative Paulsen. Thank you, Mr. Chairman, for
holding this hearing on such an important issue that is having
such a significant impact on communities across the country.
This is certainly, as has been mentioned in the testimony, a
problem that is everywhere. And, unfortunately, Minnesota has
not been able to escape the devastating effects, economic and
otherwise, of opioid addiction and the opioid crisis.
Just last month, I spoke to a mother from Maple Grove,
Minnesota, whose son bought acrylfentanyl, an analogue of
fentanyl, online, consumed it, and died. And it goes without
saying that she was devastated by the loss of her son. But she
was also devastated by the ease with which he was able to
purchase the opioid online. While it may not be within the
scope of today's hearing or committee, there is certainly a
role for Congress to play to ensure that opioids are not so
easily accessible.
Unfortunately, Minnesota was also the home to a much higher
profile opioid overdose case on April 21st of last year.
Prince, one of the most successful pop artists of all time,
passed away in Chanhassen after taking fentanyl.
My point is that this is a problem that affects many
different types of people, old and young, rich and poor, your
neighbor down the street, as well as an international
celebrity. And while it is important that we understand and
address the physical and emotional effects of the opioid crisis
on Americans, there is also value in coming to grips with the
economic toll it is taking on the country as well, which is why
I appreciate having such a great panel of witnesses here with
us today.
Let me just start with a few questions. Mr. DeWine, the
synthetic opioid fentanyl is 100 times more potent than
morphine. And carfentanil is similar but is 10,000 times as
strong as morphine, and it was developed for tranquilizing
elephants and other large mammals. In just the past few years,
fentanyl deaths have sky-rocketed. Ohio, as you have mentioned,
averaged four fentanyl deaths per year from 2007 to 2011. And
in 2015, there were 1,155 fentanyl overdose deaths.
Do you have insight into the reasons for this development
in Ohio in particular, and are there parallels or lessons that
can be drawn for other states?
Attorney General DeWine. Congressman Paulsen, thank you for
the question. You know, carfentanil is so dangerous--and
fentanyl as well, but carfentanil certainly much more--that
about a year ago we sent a bulletin out to every chief of
police and every sheriff in the State, telling him and her and
their officers, men and women of these departments, don't field
test drugs any more. Stop it. Don't touch it. We had an
experience in Ohio within the last month or so where an officer
overdosed literally because he was in the presence of this and
somehow it got into his system. So it is highly dangerous.
We believe a couple things are happening. We believe that
the fentanyl is coming in primarily from China, although
certainly some could be--actually be made in Ohio, but we think
mostly it is coming in. I know Senator Portman has been
directly involved in that concern, and Members of the House and
the Senate have been.
I think you see the drug dealers, they are great marketers.
I mean, it is amazing. This whole system is all about customer
service. And it is all about delivery. I mean, I tell people
that, if you look at heroin, Mexican drug cartels have
developed a perfect business model: They grow the poppies in
Mexico. They ship it across our southern border into Ohio. They
could control it down to the street level. At some point, they
may sell it off to the local dealers. And then what kicks in is
what I call a pizza delivery system. You pick up the phone, you
call, and they will deliver it. You get it in half an hour, and
you are going to get it cheap, but they get you started.
I am told--I am not a medical expert--but I am told that
the ratio between an early stage heroin addict and maybe a late
stage heroin addict, the amount taken could be as high as
hundred to one. So what starts as a $10-a-day habit may go to
$1,000-a-day habit. They are always chasing a high.
And the reason I think you get to fentanyl is two things.
One, it is easier for the drug dealers to get, and it is
cheaper for them, and they can make more money on it. And,
number two, it is a way to broadcast that, you know, this is
something different. This is a better high. The irony is that
when we get a situation where five, six, seven people die in a
weekend in some city in Ohio, obviously, because they were on
fentanyl or they were on carfentanil and it is a different
potency or something is there, the demand appears to go up.
So we worry--you know, we put the bulletin out, and local
law enforcement says, ``Look, be very, very careful.'' What we
worry about is that we are just encouraging people to go seek a
higher high. It is just--nothing makes sense about this. I
think it is clear that people's brains are being altered, and
the person who is buying it is not looking at it rationally or
the way you and I would be looking at it today, not being
addicts.
Representative Paulsen. Thank you, Mr. Chairman.
Representative Tiberi. Mr. Delaney is recognized for 5
minutes.
Representative Delaney. Thank you, Mr. Chairman. I want to
thank you for holding this hearing on obviously a very
important issue that affects all of our districts.
As Mr. DeWine said, this is in every community in the
country. And the fact that you have assembled such a terrific
group of witnesses, I am grateful for that.
And, in particular, I want to thank Mr. DeWine for what he
is doing in holding the pharmaceutical industry accountable.
You will make them pay like other people will, and that won't
solve the problem, but it is the right thing to do, and it will
send a message that we are going to start thinking about these
things differently.
And we believe in a capitalistic system in this country, I
certainly do, but we want it to be just at some level, and
efforts like what you are doing will help make that happen.
And it is fairly obvious what we need to do, and the
witnesses have very eloquently covered it here today. Whether
we have the commitment and conviction to do it is a question.
But the steps that Mr. DeWine is taking are obviously
incredibly important, making sure we manage ourselves through
the situation by having the healthcare system in place that can
support the people afflicted by this. And I associate myself
with the Senator from New Hampshire and her eloquent comments
about the importance of Medicaid.
Dr. Frank, your comments were very encouraging when you
talked about how private investment sees this, as effectively,
a very large business opportunity, and they are putting a lot
of money and resources against it, and there will be a lot of
innovation. So the same forces of capitalism that caused the
problem here hopefully will be directed toward solving the
problem. And so, if we are optimistic, perhaps we see a path
out of the opioid crisis.
Professor Deaton, your comments were the most sobering in
many ways. These deaths of despair are a manifestation of
something that is going on in our society, something very broad
and very significant and vexing in terms of how we deal with
it.
You know, we have allowed globalization and technological
innovation to occur, which have been extraordinarily positive
for the state of humankind, but they have been very negative--
very, very negative for certain communities in particular who
weren't prepared for it; it happened too fast. And it has been
negative for pockets really in every community and how we
confront that and the isolation, lack of security the human
beings have. You touched on it. They are not getting married.
This opioid situation was really kind of a perfect storm or the
confluence of events, almost like a match to fire based on
that. They are not moving. There is no mobility. These people
are frozen. They lack security. They are not engaging in
society the way Americans have historically engaged.
And the cost of doing nothing against this is obviously not
nothing. So, as an economist, how do you think about how we
should approach this, because it seems to me a transformative
investment is required in these communities if we are actually
going to jump start them and the citizens of these communities
out of the condition that they are in right now, which will
obviously be very expensive? But how do you think about that in
terms of not doing something?
Professor Deaton. Thank you, Representative Delaney. I wish
I knew the answer to that question. I don't--I think
globalization has been the issue. I think automation in some
ways is more of a threat to many of those jobs. There has not
been much of a decline. In fact, in most industries, there has
been substantial increase in American manufacturing output, but
the jobs are not there anymore because we don't need the labor
to do that.
I don't know. I mean, I think, you know, you saw the slides
I showed. This is not happening in Europe. And Europe is facing
the same challenges. Globalization is happening to Europe. The
pressure in jobs is the same in Europe. And one of our research
topics--I don't know the answer. I mean, my friends on the left
tend to say Europe has a much better social safety net than we
do. One of the policies that people talk about is mothers--
children get State allowances on a regular basis, which stops
mothers having to shop around for men all the time, and this
sort of merry-go-round of marriage has slowed down. But there
is a lot of dysfunction going on.
Representative Delaney. What is the cost to us if we don't
solve this problem?
Professor Deaton. Well, I think the opioid problem will get
solved.
Representative Delaney. Yeah, putting aside the opioid
problem. The more structural problem that you identified.
Professor Deaton. Well, the cost to us depends on what the
counterfactual is. I mean, do you actually think we can do
something about this? And what is that something that we can
do? And I certainly think we need to think through all
possibilities and look at some of the things that are happening
in Europe.
The German apprenticeship system seems to really hold
people together in a way that doesn't happen in this country,
for instance. I know a lot of employers are upset about the
labor force coming out of college or below is not trained for
what they want, and some sort of apprenticeship system may help
that. But I really--I don't have any surefire solution to solve
this.
Representative Delaney. That you, sir.
Representative Tiberi. The gentleman from Arizona is
recognized for 5 minutes.
Representative Schweikert. Thank you, Mr. Chairman.
Have you ever had one of those evenings where you can't
sleep, so you are up reading about what is--and I read over all
of here. I want to find an eloquent way to say because, being
from Arizona, a border State, we at least document a couple
lost lives every single day in Arizona. But in not talking--the
book from my friends on the left. I would love to actually take
a step backwards because there are things in the data--I
actually built some charts off of Dr. Frank's information. And
in some ways, I couldn't make parts of your argument work with
the chart. You know, on saying during time of Medicaid
expansion, my numbers are going up still double digits.
Are there any data sets--if we were to just wipe our minds
clean of our partisan angst and say, give me something to look
at that would help us do policy of--is it an economic driver?
Is it the synthetics that are so small they are easy to
transport and ship? Is it border? Is it demographics of the
aging of my society? If I were to try to build a number of
charts and say, here is my inflection, here is where we are
going to build our policy goal, please, someone help me build
what that policy is.
And I was going to go to Dr. Sacco. You live in this. You
have been doing this for years. You had some real interesting
stuff in your write-up. Where would you take us if you were
building the policy?
Dr. Sacco. I think some things have already started. As you
are aware, most of the fentanyl is coming from China. China
recently announced its intent to schedule four fentanyl
products. It remains to be seen whether this has an effect on
what is coming over from China.
There is, as I think I mentioned, an increased production
of heroin in Mexico and declining production in South America.
It may be worthwhile to take a look at reducing the poppy
supply in Mexico.
Representative Schweikert. But my fear is that is not my
global solution. I am just now chasing a substitution of
product.
Dr. Sacco. I am speaking to the supply side today.
Absolutely, you should speak to my colleagues about this issue.
Representative Schweikert. Dr. Frank, you have something to
say about this?
Dr. Frank. Yeah. In a sense you are asking: There is the
sort of growth problem, and there is the levels problem. On the
levels problem, if we cut the number of opioid prescriptions in
this country by 90 percent, we would still be the largest
consumer of opioids in the world.
Representative Schweikert. So, in that model, one of the
first things you would do is--let's say we could wave a wand
and elimination of prescription opioids.
Dr. Frank. No. I think it is more making sure that all our
providers are trained in the best possible practices, because I
don't think we can ignore the pain problem. We have a real pain
problem in this country.
Representative Schweikert. Okay.
Dr. Frank. So I think that we need to sort of balance the
two. And, so far, we have tipped the scale too far the other
way.
Representative Schweikert. And just from a, you know, a
junior standpoint, just looking at what the chemical compounds
were in the synthetics, it is not that hard to make. I mean,
the precursors--I am still not hearing a global--professor,
from an economist's standpoint, what is my global solution?
Professor Deaton. I wish I knew. I am more skeptical than
Dr. Frank is about treatment. I think, you know, somehow we
have to choke back the supply. I mean, it is interesting to
look back 30 years ago what happened with the crack epidemic,
which devastated a different set of communities. And I think
that that's----
Representative Schweikert. Is there a parallel we can learn
from that?
Professor Deaton. Well, I think the communities dealt with
it in the end, and it became sufficiently pervasive that the
communities--you know, it is what Attorney General DeWine was
talking about. We can educate the communities to the point
where this becomes completely intolerable. And I think we need
to be able to do that. And the schools would be a place. But
the police are working on this. And it is still true that not
all that many people know about it.
And I think the doctors really have to be choked back. I do
believe there is a genuine pain epidemic in this country. I
don't know how much of it was stoked by opioids, how much of it
was stoked by the pharma companies, but I think there is
something else there. And we have no idea how to treat that.
Representative Schweikert. Thank you, Professor.
Mr. Chairman, I am generally prone to believe this is one
of those, we do everything, from economic, to information, to
restrictions to access, to it may be there is not a magic
bullet; it needs to be an armory.
Thank you, Mr. Chairman.
Representative Tiberi. Thank you.
The gentlelady from Minnesota is recognized for 5 minutes.
Senator Klobuchar. Thank you very much. Thank you to all of
you.
I see Senator Portman is here, and along with Senator
Hassan, we have been working hard on these issues for many
years. We passed our bill last year, which, of course, set the
framework out.
And I really look at this as three different things. One is
trying to stop people from being addicted in the first place.
And that is things like getting the drugs out of the medicine
cabinet, changing doctor prescribing practices, and doing
something on stopping the huge amount of drugs out there that
are legal but aren't being used in the right way.
The second is treatment, of course.
And the third is then going after the illegal drugs. And we
are going to see more use of that as we hopefully can reduce
the number of legal drugs that are going out and getting people
hooked.
So, along those lines, Attorney General, I was really
interested and happy to see that you brought that lawsuit
against five opioid manufacturers alleging that the drug
companies engage in fraudulent, deceptive marketing campaigns
about the risks and benefits of these opioids. I know there was
a settlement in West Virginia on a similar case. The idea is
the money, of course, goes into treatment. And it seems to me
that the people responsible for marketing these drugs should
pay for the human costs of what has happened here. So can you
talk about what you can about that lawsuit and how you think it
could be replicated across the country? Because all the
education we are doing isn't getting us the money we need for
treatment, and it is not stopping the bad guys from getting
people hooked. And by that, I don't mean illegal drugs.
Attorney General DeWine. Senator, thank you for the
question.
You know, I made it plain last week when I held a press
conference that--when I explained what we were doing and why we
were doing it. One thing I said to my Ohio citizens is this is
not a substitute for the hard work at the local level. I am
convinced that the work has to be done at the local level.
I started seeing 5 or 6 years ago, when we were dealing
primarily with the pain med problem, that the communities that
were making the most progress were communities where it had
gotten so bad, they just got sick of it. And it was usually a
grassroots effort led by a mom. Sometimes a dad, but it is
usually a mom. And they just go and they try to transform the
culture in that community.
Senator Klobuchar. But do you think a lawsuit, which I
believe, like in the tobacco industry, the lawsuits actually
got the information out there and----
Attorney General DeWine. Sure. Yeah.
Senator Klobuchar [continuing]. It stopped people from
doing bad things?
Attorney General DeWine. Yeah. Let me get to the second
part, Senator. Thank you, very much.
We believe this lawsuit is a fair lawsuit. We believe that
what the evidence will simply show is that the pharmaceutical
companies, beginning in the late 1990s, tried to change the
culture. The culture, historically, had been, for pain meds,
that they are used for acute pain. You have your tooth taken
out, you take it for a day, 2 days, 3 days, or it is used at
the end of life when you have someone who is terminally ill.
What the pharmaceutical companies did is they tried to
convince doctors, and did convince doctors, that, hey, it was
just okay to use it for a third purpose. And that third purpose
was for pain----
Senator Klobuchar. Pain management.
Attorney General DeWine [continuing]. That goes on day
after day after day but is not terminal. And they did it, and
they were very successful in doing it.
In response to your question, one of the things I would
like to see these companies do--and they can do it tomorrow and
start, lawsuit or no lawsuit--is to spend some money to change
the culture back to where the culture should be, which, as
several of you have said, is somewhere in the middle.
Senator Klobuchar. Thank you.
And we also have a bill with Senator Manchin that would put
a fee on some of these drugs, and have, again, that go, per
milligram, have that go to treatment.
And so I guess, Professor Deaton, congratulations on your
good work. Can you comment on what the attorney general has
done here, which I think is commendable, and how sometimes
lawsuits can change the economic situation if companies are
afraid of getting sued, that it is not just public shaming but
actually out of their bottom line, that that can make a
difference in how they behave?
Professor Deaton. Thank you, Senator.
Yes, I think it can make a difference. I mean, I don't have
the figures, but the LA Times reported that family that owned
OxyContin had made $31 billion from it by the middle of last
year. This is at a time where that drug is killing large
numbers of people, and I think, you know, we ought to make it
clear that this cannot be tolerated.
I also agree with the attorney general that the local
effort is where the culture will be changed. But we don't need
pharma companies trying to push doctors to prescribe addictive
opioids for lower back pain.
Senator Klobuchar. Right. It just makes me cry when you see
all these rehab people and small town mayors and cops are all
trying to do the right thing, and then these people are getting
a different message either on TV or when they go into the
doctor's office. And it just has to change.
Thank you.
Representative Tiberi. Thank you.
It is an honor to introduce my Senator, who has been a
national leader, as you know, Attorney General, on this issue,
and talked to me last session of Congress about introducing a
bill, which I did, that you have been a leader on, the STOP
Act, deals with this issue of fentanyl coming in from China.
Mr. Portman, you are recognized for 5 minutes.
Senator Portman. Thank you, Chairman Tiberi, and thanks for
your leadership all along and more recently taking the lead on
the STOP Act. I think you have 165 cosponsors, I am told. And
thanks to CRS for helping us with that situation, and to Mike
DeWine for his help, both as the top law enforcement official
in the State of Ohio who cares a lot about the supply side and
keeping this poison out of our communities, but also someone
who gets it, that this is ultimately going to be solved through
a comprehensive approach focusing on the local community. I was
in this room 20 years ago as a House Member trying to get
legislation through called the Drug-Free Communities Act, which
is now a law that has helped spawn over 2,000 community
coalitions. Our whole focus was local, including one that I
founded and chaired in Cincinnati.
And yet here we are: The worst drug crisis in our history,
by any measure, worse than it has been in the past. And I think
what we have learned today from this terrific panel of experts
and also from some of our colleagues, including Congressman
Schweikert, is that, Mr. Chairman, the comprehensive approach
that you have been advocating is the only way, and it has to be
at every angle. And it has to include much more aggressive
prevention and education efforts. Senator Klobuchar and I are
cosponsors and authors of this STOP Act. Senator Hassan, one of
our original four cosponsors, by the way, is here too. Senator
Klobuchar, along with me, Whitehouse, and others, pushed this
comprehensive approach in the Comprehensive Addiction and
Recovery Act, called CARA. It includes a big component of
education and prevention that has yet to be implemented,
including a national awareness campaign on making this
connection, as Attorney General DeWine has made clear today,
between prescription drugs, and heroin, fentanyl, and other
opioids. And I think Professor Deaton is right: A lot of people
don't make that connection because they are not aware of the
information. So, when you go to a doctor and someone who you
trust prescribes opioid pain medication and says, ``Here is 60
Percocets, take this for this oral surgery you have had,'' you
trust that doctor, and you do that. And for some people, there
is, obviously, a change in their brain, which is the disease of
addiction.
And there are other aspects of the CARA legislation that
need to be implemented, and I have urged the Obama
administration, as I am now urging the Trump administration to
move quickly in implementing these things in the face of this
crisis.
Couple quick questions, one to Attorney General DeWine--
and, again, as the chief law enforcement officer in our State,
you know much better than I what is going on. But I just got an
email yesterday from the coroner in Cuyahoga County, Chief
Medical Officer Dr. Gilson, who was here testifying about the
week before last over in the Senate, and he reported to me that
43 people have died in Cleveland in the couple of weeks since
Memorial Day. He believes it is fentanyl-driven. By the way,
this is in contrast even to the horrible rate of overdoses and
deaths last year of being, you know, more in the 20 to 30
range. We are now even this year--in April, it was under 40.
Now, in 2 weeks, over 40.
So can you talk a little bit about what has happened in
Ohio and maybe specifically what I am hearing back home, which
is this notion, to Professor Deaton's point about who is being
affected, that this is now being spread into the African
American community more now with regard to these evil
traffickers sprinkling fentanyl in cocaine and starting a whole
other series of addictions? If you could just speak to that a
little bit, I would appreciate it.
Attorney General DeWine. Well, Senator, thank you very much
for the question. Thank you for the great work that you have
done. You have been a real leader in this field.
You know, I think there is a natural progression which
starts generally with the pain med, 35-year-old, 40-year-old,
blue-collar male hurts his back, is prescribed pain meds,
becomes addicted to it, and everything goes downhill from that.
He moves over to the heroin because it is cheaper and it is
maybe more available.
And then the other thing that you have, as you point out,
going on, is fentanyl now. And the fentanyl, we are finding
fentanyl a lot more now, more, and more, and more, and less and
less heroin. It used to be it was sprinkled in with it. One of
the things that we are seeing in our crime lab is that these
cases are much more complex and take longer to do because,
instead of it being all heroin or all fentanyl, it is all mixed
up. And so it slows that down.
But I go back to something I said a moment ago. I think it
is a marketing technique. And these people who are selling this
stuff, who are killing people, they are good marketers. And it
is all about service. And it is all about getting the best
high. And part of the marketing is, ``Hey, we got something
new,'' and that something new may, in fact, be fentanyl.
As far as it moving more into the African American
community, I don't have any data on that, but, sure, it would
appear that. That anecdotally would appear that it is getting
pushed out.
And, you know, as I look at this problem from maybe a big-
picture point of view, sometimes people will ask me, ``You
know, Mike, what keeps you awake at night as the attorney
general?'' My quick answer is ``the opiate problem.'' I think
it is a bigger problem. It has been alluded to by several
people here today. The opiate problem is a subset of a bigger
problem. The bigger problem is that we have a large number of
people in Ohio and other states who are not living up, for many
reasons, to their God-given potential. And we have got a
problem with people not having the right skills, and that does
impact this some--not in every case. We are seeing a lot of
middle class people who everything would appear to be going
fine in their life, but there is something going on there that
causes that person to become addicted.
But a related problem is the fact that we have got Ohioans,
and people, I am sure, in other states, who are not living up
to their God-given potential because they are addicted or--and/
or, usually, many times--they don't have the education. As the
professor said, they do not have the education. They do not
have the set of tools to make it. And part of it is we do have
to, I think, start saying to people, and we have to start--
parents need to be saying to their kids: We want you to live up
to your full potential. Maybe you are working with your hands,
and you don't go to college, but maybe you go to, instead, an
apprentice program or something else where you can become a
welder or you can become a machinist and make a very good
salary.
So I think all of these things are tied into each other.
And part of our challenge in Ohio and other states, I think, is
to focus on kids who are growing up--because it is easier to
impact them than it is to--it is not that we are not going to
try to impact someone older--but the kids that are growing up,
and make sure that they have all the opportunities that are
there no matter where they are born and no matter what their
income or who their dad is or who their mom is. And I think, to
me, that is part of our solution as we look at the pain med
problem.
Senator Portman. Thank you. My time has expired.
Thank you, Mr. Chairman, for your indulgence.
I am going to have some questions for you, Professor
Deaton, for the record, about the economic impact of what you
described. And I think the notion of opioids being an
accelerant to what you and Attorney General DeWine just talked
about is actually an apt description.
Thank you, Mr. Chairman.
Representative Tiberi. Thank you.
The gentleman from Virginia is recognized for 5 minutes.
Representative Beyer. Thank you, Mr. Chairman.
And thank all of you, very much, for being here.
It is fascinating. It at least looks like a triangle in
terms of there is the supply problem, as argued by Attorney
General DeWine and Dr. Sacco. There is the economic
dislocation, the hopelessness, from Professor Deaton, and then
the treatment side from Dr. Frank.
Dr. Frank, can you cite the reasons why those with an
opioid abuse disorder would not seek treatment?
Dr. Frank. Yeah. About a little over half don't seek
treatment because either they can't afford it, which is the
biggest chunk, or there are no providers available to them. And
so that is a little bit more than half.
And then the other main reasons have to do with stigma in
the workplace, in the community, and also there are a lot of
people who deny that they have a problem.
If I could take one other second, I just want to kind of
clarify the issue around treatment, which is medication-
assisted treatment is really the most effective treatment we
have. But only about a quarter of the people who get treatment
get that. And so we are undershooting our potential by a great
deal. And that is what, in a sense, causes us to underachieve.
Representative Beyer. Thanks.
You know, we have the ObamaCare reform, replacement, repeal
bill, is in the Senate right now. I think Cassidy said he wants
to make sure it passes the Jimmy Kimmel test, which the House
bill clearly didn't pass. But I am hoping that, based on all
that we are learning now, and Senator Portman talked about this
is the worst addiction crisis in the Nation's history, that
whatever bill comes out of the Senate would pass the opioid
epidemic test.
Professor Deaton, you said this really hasn't hit Europe
yet. That might just be a temporary reprieve. Can you explain
why the fentanyl from China and others hasn't affected that
population at least yet?
Professor Deaton. At least yet.
I mean, that is for us--I guess it used to be the $64,000
question, now the $64 billion question. You can see some of
this in the English-speaking countries of the world. You see
some of it in Canada. There is a little bit in Britain and in
Ireland and Australia, perhaps a little bit in Denmark. And if
you looked at those countries just by themselves, you would be
worried about it. But when you put it in the context of the
U.S., there is nothing happening there.
Partly, I think, it is because the prescription drugs are
controlled much more carefully in Europe, and they are used in
clinical, acute settings, and they are not prescribed in the
community--yet. But, I mean, there is a concern that they will
spread out into the community.
And I think the fentanyl thing, I don't know. But the black
tar heroin, for instance, is coming from Mexico, and they have
very easy targets here, and maybe fentanyl will come to Europe
in the same way too.
So I think the Europeans ought to be worried, and they
ought to--you know, they ought to make sure that they don't get
to where we have gotten to. And they want to be very careful
about it. But we don't see the signs of this epidemic, and I
think part of it is the control of----
Representative Beyer. Thank you.
Dr. Sacco, you have been, it looks like, studying this drug
thing for many, many years, academically and in CRS. What did
we learn from the crack epidemic that is relevant to fighting
the opioid epidemic?
Dr. Sacco. I am sorry. You said what did we learn from the
crack epidemic?
Representative Beyer. Yeah. Are there lessons from the
crack epidemic that are relevant here?
Dr. Sacco. I am not sure I can offer an opinion on that
today.
Representative Beyer. Okay.
Dr. Sacco. It is a little bit outside of the scope of what
I am prepared for. But I am happy to follow up with you. Is
there anything specific to the crack epidemic?
Representative Beyer. Well, for example, we seemed to have
responded to the crack epidemic, for example, with lots of
incarceration. We were pretty harsh about that.
You know, there has been a movement, bipartisan, in the
criminal justice, away from, you know, criminalizing
essentially nonviolent drug offenders or the harshness of it;
perhaps not with the Attorney General recently. But is that a
solution here, too, or do we tilt toward the treatment side?
Dr. Sacco. I can't advise one way or the other. I can tell
you that drug offenses account for the majority of Federal
offenses carrying a mandatory minimum, if that is what you are
speaking to. Mandatory minimums did come out of that era of the
crack epidemic. And there are different ways of looking at the
efficacy of mandatory minimums. From an economic standpoint,
research says that lengthy mandatory minimums are not cost-
effective and that other factors, such as certainty of arrest
and prosecution, have a greater deterrent effect than the
severity of the punishment. So, in other words, a 1-year
sentence has the same deterrent effect as a 10-year sentence.
On the other hand, incapacitation prevents an individual from
committing harm to society for that set period of years.
At the same time, it is not clear if that punishment
reduces crime. Often, low-level drug offenders are easily and
quickly replaceable.
Representative Beyer. Thank you very much.
Mr. Chairman, yield back.
Representative Tiberi. Thank you.
The gentlelady from Virginia is recognized.
Representative Comstock. Thank you, Mr. Chairman.
And thank the witnesses for being here today.
We have seen in my district--and I am in northern Virginia,
here just over the bridge here. And we have had a rise in MS-13
gangs getting more involved now in trafficking of heroin and
opioids. And so we are seeing this convergence of, you know,
very violent gang, and them preying upon some very young
people, both trying to recruit younger people into the gangs
but then also getting them involved in these various things.
You know, what kind of effect--are you seeing anything like
that? Are you seeing that elsewhere? Or how that is going to
impact the economy? And what we see, you know, particularly
when you get these young people, that they are getting into
these gangs, and it is a whole lifestyle, and that is how they
are making a living. They are not getting educated, and it will
be even a worse situation.
Attorney General DeWine. I am sorry. Is that addressed to
me?
Representative Comstock. Sure. That would be great,
Attorney General.
Attorney General DeWine. I am not sure I can really answer
that question. What I can say is that, when we look in Ohio,
you know, our violent crime in our cities, a great extent of
that is driven by gangs. And there is, many times, a connection
between drug trafficking and the gangs.
Representative Comstock. And I know we have been focusing
on the lower income, and how we have seen the rise there, but I
know we have seen--in my district, we have, you know, very
high--a lot of high-income areas in this region, and we are
seeing it hitting everywhere. So I did want to make sure here
today, even though it was focusing on that lack of opportunity,
we are seeing this in every community and with every aspect.
And so what is the difference when you are seeing, say, you
know, a college-educated kid who maybe just got addicted to
these from a sports injury and then just, you know, took it too
far, and then they are in this lifestyle? What are you seeing,
the difference between, you know, somebody like that versus,
you know, this expansion in a lower income area?
Professor Deaton. Thank you very much.
Representative Comstock. Professor, thank you.
Professor Deaton. I think income is not the best marker of
this, partly because African Americans tend to be--there are a
lot of low-income African Americans, and until recently,
African Americans have been largely exempt from this epidemic.
That does seem to be changing, and there is a tick up in the
last 2 or 3 years in mortality of African Americans from
opioids. And that may be fentanyl, and that may be spilling
over into those communities. But low education has certainly
been an issue. And what you say is true, that higher education
are suffering from this too but nothing like to the same
degree. I mean, this huge explosion has been among people with
only a high school or even some college, but with a B.A., it is
much, much less. You certainly find people, for sure. It is
everywhere. But it is throughout the community.
I think, also, some of the standard protective forces from
people have sort of broken down. I mean, one example I like to
give is Utah has always been a very healthy place compared with
Nevada and for sort of obvious reasons. But Utah has not at all
been exempt to this epidemic. And that is because, you know,
Mormons tend not--they don't drink. They don't smoke. They
don't do things that are bad for your health. But when your
doctor gives you pills, that is not something you are
programmed to resist, and the church has not been very good at
dealing with that.
Representative Comstock. So the education efforts and the
comprehensive approach that Senator Portman and others were
talking about and the attorney general was talking about,
really, at that young age, kindergarten, and making sure--
education efforts really needs to go everywhere then.
Professor Deaton. But stop the docs pushing this----
Representative Comstock. Yeah.
Professor Deaton [continuing]. So that people know it is
dangerous.
Representative Comstock. Thank you.
I yield back, Mr. Chairman.
Representative Tiberi. Thank you.
The gentleman from Illinois is recognized for 5 minutes.
Representative LaHood. Thank you, Mr. Chairman, for this
hearing today and for this subject matter.
And I want to thank the witnesses for your valuable
testimony here today. I have seen the devastating effects of
opioid abuse and heroin deaths in my own district. I represent
a district of 19 counties in central and west central Illinois,
a very rural district, and did a series of townhall events
related to this issue with all the stakeholders, and it
continues to be a problem.
We have talked a little bit here today about some of the
analogies to this epidemic, and we talked a little bit about
crack cocaine. I spent 10 years as a State and Federal
prosecutor. And I think back to, in Illinois, 20, 25 years ago,
we had a real problem with drunk driving. It was the number one
killer in Illinois of young people.
And so what happened? We had an aggressive law enforcement
effort. We raised awareness, a lot of tragic deaths. But we
also had Mothers Against Drunk Driving, which played a
significant role from an organic level, kind of like what you
talked about, Attorney General DeWine. We also used technology,
ignition interlock.
So, today, we have some of the lowest levels of drunk
driving deaths anywhere in the country. And that is because of
an effort. And it was a movement at the time to do that. And I
think about that analogy here today.
The addiction is much different here. But we are able to
reduce that problem and solve that in a variety of ways. And I
think you have to--we have talked about this--holding everybody
in the chain accountable all the way through. And I am not sure
we are doing enough of that right now. And we have touched on
some of those things.
Attorney General DeWine and then Dr. Frank, you want to
comment on that?
Attorney General DeWine. Well, Congressman, I totally agree
with you. This comes at the local level, comes at the State
level. Certainly the Federal Government can play a role. But,
ultimately, I think it comes back to the individual community.
And, you know, what we have seen in Ohio in this area is the
communities that have started to make some real progress,
number one, admit they have a problem. Number two, there is a
citizens group that is put together by a mom who has lost a son
and lost a daughter. And they go out, and they just--they
change the culture. Now, you still have a problem. But they
make some progress.
I saw it in my own career. I introduced a bill in the Ohio
legislature, a drunk driving bill, and people were laughing at
it. It was back in the early, early 1980s. And it was the
Mothers Against Drunk Driving, frankly, who got it passed,
Representative LaHood. Yep.
Attorney General DeWine. And it just shows that--you know,
it is the example I think we can all use with people: look, you
can make a difference. You can change the culture. You can
change what people are talking about by a very active citizens
group, either at the local level or the State level or the
national level.
Representative LaHood. Dr. Frank, you know, people also
remember when we talk about drunk driving about, you know, the
TV commercials that talked about these tragic deaths and
highlight of just how horrific some of these were. And I am not
sure that we have that level. And if we have, maybe there are
some states or local areas that we can use as a success model
on that.
Dr. Frank. Yeah. I do want to offer a ray of hope, because
we haven't had much here today. And that is one area that we
have been really successful on is in reducing the number of
prescriptions on methadone for pain. It used to be that they
were 6 percent of the prescriptions in opioids and 30 percent
of the deaths. And we have turned that around. And the way we
have turned it around is, I think, by being very aggressive in
training and educating of the physician community, making sure
that our prescription drug monitoring programs really focused
on that, and then CMS, through the Medicaid program and through
Medicare, took measures to issue guidance to states and to do
edits in the prescription drug plans under part D. And together
they really brought down those prescriptions. And I think that,
you know, in a sense, that is a reflection of the sort of
multipronged approach. And I do think that that offers us a bit
of hope here.
Representative LaHood. Professor Deaton, you touched a
little bit on how we maybe hold doctors accountable and what we
need to do. And much of that oversight on doctors and
physicians is done at the State level. Is there an example of a
State that has done a pretty good job in terms of holding
doctors accountable?
Professor Deaton. I am afraid I don't have an answer to
that. We have done very little work on the geographic aspects
of this epidemic. So I can't answer that. Thank you.
Representative LaHood. Thank you.
Thank you, Mr. Chairman.
Representative Tiberi. Thank you.
I really appreciate all four of you being here. What great
testimony we were able to hear today.
I am going to allow the acting ranking member, the
gentlelady from New Hampshire, have some final comments as
well.
Senator Hassan. Thank you, Mr. Chair.
And thank you all on behalf of Ranking Member Heinrich and
myself for being here and for your testimony.
And I just wanted to close with the thought of a particular
constituent of mine who is now in recovery from heroin
addiction, because I think it is important, as we have had this
discussion, to remember that ultimately this addiction is a
disease. It is caused by a chemical reaction in the brain. And
it is because people like my constituent, Ashley, who woke up
one morning to find her husband having overdosed and died next
to her, went and got treatment under Medicaid expansion, that
she has gotten well. And she now is working. And she is getting
her health insurance through her private employer. She is off
of Medicaid expansion.
And I think it is really important that we--also to
acknowledge the comments we have had about the importance of
community response--thank the people who have this disease who
have stood up, who have identified themselves as people
suffering from addiction, have done the hard work of getting
better, and then have turned their efforts to make sure that
they help with the prevention and recovery efforts that we need
to undertake.
So I am going to keep Ashley in my thoughts today. She is
about 17 or 18 months in sobriety now. She continues to get
treatment for recovery. She is going to be reunited with her 3-
year-old son soon. There is hope if we go at this with the all-
of-the-above approach.
Thank you so much.
Representative Tiberi. Thank you, Senator.
Thank you again. There are stories like that that we all
can share. Attorney General DeWine has shared many with me, as
he is on the front lines. And I appreciate, and I think this
entire panel, if you couldn't tell, appreciates the time you
put into this testimony. You all complemented each other quite
well. This is a battle that we are going to continue to fight
in a comprehensive way, and I appreciate the knowledge that you
were able to share with us today. And we look forward to
working with you in the future.
The record will be open for 5 business days for any Member
that would like to submit questions to the four panelists for
the record, and our hope is that you would respond as well.
This hearing is adjourned
[Whereupon, at 11:37 a.m., the committee was adjourned.]
SUBMISSIONS FOR THE RECORD
Prepared Statement of Hon. Patrick J. Tiberi, Chairman, Joint Economic
Committee
Good morning and welcome. I want to welcome especially our Ranking
Member Senator Heinrich and our Vice Chairman Senator Lee, as well as
the other Members of this Committee, who have joined me in expressing
the importance of holding a hearing on the threatening increase in
opioid abuse.
Drug abuse has become rampant in America and may be the worst the
country has experienced. It is devastating families and degrading
communities, and undermining parts of the economy.
For several states and districts represented by members of this
committee, the problem is acute. As Figure 1 indicates, the crisis has
a regional character. My hometown of Columbus, Ohio is part of the
crisis' epicenter east of the Mississippi.
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Figure 2 shows the 2015 drug overdose death rates by State, which
ranged from 40 per 100,000 in West Virginia to six per 100,000 in
Nebraska. The states represented by members of this committee among the
ten highest rates, are highlighted in red, including my home State of
Ohio, which ranks third.
Drugs markets, both legal and illegal, can be analyzed from the
demand and the supply side. The exact reasons for the extent of drug
abuse are not clear at this point. With respect to demand, a changing
perception of pain as a health problem in the 1980s by the World Health
Organization in particular laid the ground for more intensive
treatment.
The labor market and the economy can have a major impact on demand,
although not necessarily in ways one might expect. Some research shows
less substance abuse when unemployment increases, for instance. And,
while prolonged downturns in labor market and economic conditions are
associated with social, behavioral, and health problems, they do not
necessarily affect all groups in the same way or to the same degree.
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
All of society is vulnerable to the opioid epidemic, but it is
compounding the economic distress that certain parts of the country and
segments of the population already have been experiencing. Some areas
of high unemployment tend to have higher rates of substance abuse. The
Economic Innovation Group, a representative of which testified at our
last hearing, The Decline of Economic Opportunity: Causes and
Consequences, developed an economic distress index consisting of
several economic indicators, a national map of which is shown alongside
the map of overdose deaths in Figure 3. The darker the red, the worse
the distress. Striking correlations are visible.
But it is also apparent from Figure 3 that some economically
distressed areas are not experiencing high overdose death rates.
From the supply side, the particular locations where new, potent
drugs initially happened to become most readily available, and the path
of geographic market expansion they took, track a visible trail of
destruction in Figures 1 and 3. Without question, new developments in
the sourcing, cost of production, potency, and retail delivery have
moved the supply of both legal and illegal addictive drugs
substantially to the right. Newly effective pain medication, OxyContin,
introduced in the mid-1990s had initially unacknowledged addictive
qualities and was overprescribed. So-called black tar heroin, more
powerful and less expensive than other kinds, expanded its market share
just as OxyContin was reduced in potency.
The prescription drug explosion started in the Appalachian part of
Ohio and spread to parts of Kentucky and West Virginia. Black tar
heroin entered the Southwest and spread westward but eventually also
eastward, crossing the Mississippi in 1998.
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Illegally distributed variations and counterfeit forms of
prescription drugs like fentanyl can be poisonous and kill a person
even in small doses, some by mere contact with the skin. We now face
pure poisons masked as narcotics that are shipped across our borders.
Senator Portman and I have introduced the STOP Act, which aims to stop
dangerous synthetic drugs from being shipped through our own postal
service, keeping them out of the hands of drug traffickers in the
United States.
But it would be a mistake to blame these drugs entirely for the
rise in mortality that some groups and regions are suffering. There are
other causes apparently emanating from long-term changes in the
composition of the economy and of skill requirements.
Determining cause and effect is obviously critical to reaching the
right conclusions. Feedback effects often complicate causality and make
a clear understanding of major causes difficult. For example, does a
bad economy lead to drug abuse or does drug abuse to a bad economy by
lowering productivity, labor force participation, and social cohesion?
We will hear perspectives that run in both directions today.
We will hear about the economic decline of certain groups leading
to despair and self-destructive behavior; of damage drug abuse causes
individual lives, families, and communities in all segments of society;
and of developments in the production and marketing of addictive drugs,
which have made them more dangerous, affordable, and available.
I look forward to most insightful testimony from our panel of
experts.
__________
Opening Statement of Hon. Martin Heinrich, Ranking Democrat, Joint
Economic Committee
Thank you, Chairman Tiberi, and thank you to our panel for being
here today.
Addiction to heroin and prescription opioid pain relievers is a
public health epidemic that is devastating families and communities
across the country.
Every day, 91 Americans die from an opioid overdose.
Over-prescription is partially responsible for the epidemic.
Since 1999, the amount of prescription opioids sold in the U.S.
nearly quadrupled and so too has the number of overdose deaths from
opioids.
The economic costs of addiction are enormous--totaling more than
$80 billion in 2013 from increased health care costs, higher rates of
incarceration, and lost productivity.
New Mexicans know too well the devastation heroin and prescription
opioids can wreak.
For years, without adequate treatment resources, communities in New
Mexico have suffered through some of the highest rates of opioid and
heroin addiction and overdose deaths in the Nation.
Rio Arriba County has a drug overdose death rate of 81 per
100,000--five times the national rate.
I'm reminded of Josh from Espanola, who I met at a round table I
hosted in Rio Arriba County last spring.
At 14 years old, Josh became addicted to prescription opioids.
Over time he moved to heroin. He stole from family and friends to
maintain his growing addiction.
Josh spent time in jail where he went through the pains of
withdrawal. He even attempted suicide but his gun didn't go off.
Now in his 20s, Josh has turned his life around because he finally
got access to treatment and services.
For millions of Americans, proven substance use treatment is
available because of 1) behavioral health parity laws, and 2) the
Medicaid program.
In New Mexico, Medicaid--called Centennial Care--is at the
forefront of our fight against the opioid crisis, accounting for 30
percent of life-saving medication-assisted treatment payments for
opioid and heroin addictions.
At exactly the time Congress should be giving states more tools to
fight this epidemic, House Republicans passed a bill that would repeal
Medicaid expansion, artificially cap the program, and shift the burden
about who and what to cut onto states.
More than a million people who have been able to secure treatment
for substance abuse would lose their coverage.
Repealing Medicaid expansion would cut about $4.5 billion from
treatment for mental health and substance abuse.
We can't fight a public health crisis with grant dollars alone.
Grant dollars run out. Block grants lose their buying power over time.
And private investment dollars--which are critical in this fight--
won't come without certainty that the foundation is funded.
Unfortunately, I won't be able to stay to hear your important
testimony because of a hearing in the Intelligence Committee.
But I will be leaving you in the very capable hands of my
colleague, Senator Hassan.
New Hampshire loses at least one person every day to a drug
overdose. As Governor, Senator Hassan used every tool at her disposal
to fight the epidemic, including turning to the flexibility of the
Medicaid program to gain ground in her State's fight.
I will let her to tell you more, but I leave you with this: when a
community faces a public health crisis, it's not long before a State
turns to the Medicaid program to stem the tide.
What will our states and communities do for this public health
crisis--and the next one--without the guarantee of Federal Medicaid
dollars to support them?
Thank you, Senator Hassan.
Mr. Chairman, I'd like to yield my remaining time to Senator Hassan
for brief remarks.
__________
opening statement of senator margaret wood hassan
Thank you Chairman Tiberi, Ranking Member Heinrich, and to our
witnesses for being here today.
As I travel across my home State of New Hampshire, I've heard from
countless families and those on the front lines about how the heroin,
fentanyl, and opioid crisis has devastated communities across our
State.
And I know that many of our colleagues have heard of the impacts in
their states as well.
I'm proud that during my time as the Governor of New Hampshire,
Republicans and Democrats put our differences aside and came together
to pass--and reauthorize--our State's bipartisan Medicaid expansion
plan.
Medicaid expansion is providing quality, affordable health coverage
to more than 50,000 Granite Staters, including coverage for behavioral
health and substance use disorder treatment. And experts have said it
is the number one tool we have to fight this crisis.
We should be coming together--just as we did in my home State--to
support those on the front lines and help those who are struggling with
addiction. And while members of both parties and the Administration
have discussed the severity of this crisis, we need the words to be
matched by strong action.
What we cannot do, however, is end Medicaid expansion and institute
deep and irresponsible cuts to the traditional Medicaid program.
This crisis is a public health and law enforcement issue, but it is
also an economic issue. I believe the investments in helping people
recover are a far better use of our dollars than the long-term costs of
addiction, both in terms of State budgets but also in ensuring that
individuals are healthy enough to contribute to our economy.
I am pleased that we are having this hearing today, but we need to
continue to hold hearings on how proposals made here in Washington
would affect our ability to stem and reverse the tide of this epidemic.
This is an issue that rises above partisanship, and this is the
work that we need to be doing--because the lives of people in our
states depend on it.
I am going to continue to work with our colleagues on solutions,
while standing firm against any policy that would pull us back.
Thank you, and I look forward to hearing from our witnesses.
__________
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Prepared Statement of Ohio Attorney General Mike DeWine
Thank you, Chairman Tiberi, Vice Chairman Lee, and Ranking Member
Heinrich for inviting me to testify at this very important hearing
today on the opioid epidemic in Ohio.
Ohio is facing the worst public health crisis in our lifetime,
leading the Nation in opioid overdose deaths. In 2015, 85 percent of
all accidental drug overdose deaths in Ohio were caused by an opioid.
According to new data recently released by the Columbus Dispatch, 4,169
Ohioans died from accidental drug overdoses last year--that's a 36%
increase over 2015.
Cuyahoga County Medical Examiner Dr. Thomas Gilson recently
testified in front of a U.S. Senate Committee that those who are
addicted to drugs in Cuyahoga County, which includes the City of
Cleveland and suburbs, would fill the First Energy Stadium where the
Cleveland Browns play (73,000-plus), and those who switch to fentanyl
each year would fill the Quicken Loans Arena, home of the 2016 world
champion Cleveland Cavaliers (20,000-plus).
We are seeing this scourge in the Ohio crime lab. In 2010, the Ohio
Bureau of Criminal Investigation (BCI) had only 34 cases of fentanyl,
but in 2016, we had 2,396 cases. In fact, more fentanyl came through
BCI in 2016 than had come through in the previous five years combined.
And BCI went from zero cases of carfentinil--an elephant tranquilizer--
in 2015 to 214 cases in 2016. Our organized crime drug task forces have
already seized more fentanyl in 5 months of 2017 (30.8 pounds seized)
than in all of 2016 (27 pounds).
Four out of five individuals now suffering from heroin or fentanyl
addiction first started down this road by using prescription opioids.
In 2010, when I first ran for Attorney General, my wife Fran and I both
learned of the families who were ravaged by addiction to prescription
pain meds and the pill mills that were fueling it, especially in
southern Ohio. When I took office, we started going after the doctors
who overprescribe these painkillers. Since that time, we have revoked
the licenses of 90 doctors and 22 pharmacists.
Last week, my office filed a lawsuit against five of the leading
prescription opioid manufacturers and their related companies in the
Ross County Court of Common Pleas. The lawsuit alleges that these drug
companies engaged in fraudulent, deceptive marketing campaigns about
the risks and benefits of prescription opioids, leading doctors to
believe that opioids were not addictive, that addiction was an easy
thing to overcome, and that addiction could actually be treated by
taking even more opioids. As a result, we believe the evidence will
show that these companies got thousands and thousands of Ohioans
addicted to opioid pain medications, which has all too often led to use
of the cheaper alternatives of heroin and synthetic opioids.
This lawsuit is about accountability. It should not be looked at as
a substitute for the many things we now must do to battle addiction--
nor should it be looked at as a quick fix.
That's why my office is taking a holistic approach to combat the
problem.
We must continue our efforts to go after drug dealers. We must
continue our outreach work with local communities. And, we must
implement our recommendations for early drug abuse prevention education
in schools.
In 2013, we established a heroin unit in my office that includes
lawyers, investigators, and community outreach liaisons. They fight the
opioid battle on both the law enforcement side and on the community
outreach side. Our community outreach team works on grassroots efforts
that include bringing together law enforcement, schools, clergy,
business leaders, and other citizens to help form a plan specific to
that community to address the drug problem. This team helps communities
identify needs and recommends resources to address those needs. And,
earlier this year, we held an opiate conference in Columbus, with over
1,300 people in attendance, about the opioid crisis and talk about
efforts that are working across Ohio to help families and communities.
To make a real difference in this fight we also need to teach our
kids early about the dangers of drug use and how to make good
decisions. In the 1980s, I served on President Reagan's National
Commission on Drug Free Schools. The experts we talked to told us that
repetitive, comprehensive, school-based education was necessary to
successfully combat drug addiction.
I have often said that there has been a cultural shift in the wrong
direction in how our society views drug abuse. The psychological
barrier that once stood in the way of someone taking deadly drugs is
simply gone. To address this, the Speaker of the Ohio House Cliff
Rosenberger and the former Ohio Senate President Keith Faber and I
convened a group of experts on education and drug prevention. They
recently issued 15 recommendations, including the need for consistent,
age-appropriate, evidence-based drug abuse prevention education in
kindergarten through 12th grade. The recommendations are not mandates.
However, if progress is not made, we must ensure communities are
instituting prevention efforts to reach youth before it's too late.
Further, if we are serious about changing the culture around
substance abuse, we must engage the best and brightest in the private
and public sectors to create a statewide anti-drug campaign. We can
change the public mind-set through messaging on social media,
television, and other mediums.
Local law enforcement is doing some great things, and we need to
replicate efforts that work--programs like Lucas County's Drug Abuse
Response Team, created to help addicts navigate the treatment system.
What's unique about this program is that law enforcement officers
develop personal relationships with addicts, investing both time and
compassion.
Ultimately, breaking free from addiction in the long-term requires
access to services across a continuum of care--a holistic, wrap-around
approach from overdose to sobriety. Most Ohio counties have gaps in
that continuum, and we must address the different needs of each local
community.
Tragically, children and babies are the silent victims of this
epidemic. Babies born with neonatal abstinence syndrome because their
moms were addicts spent approximately 26,000 days in Ohio hospitals in
2014, with health care costs totaling $105 million. And our foster care
system is overflowing with kids. At least 50% of kids and 70% of
infants placed in Ohio's foster care system have parents with opiate
addictions, costing the State an estimated $45 million per year.
My office is funding an innovative new pilot program in 19 southern
Ohio counties called START that increases resources to children's
services agencies for intensive attention for both children and parents
to promote recovery and family reunification. We hope to be able to
expand this program to every county in Ohio.
The opioid epidemic is a human tragedy of epic proportion. No doubt
the human toll would be much greater, though, but for the life-saving
effect of the drug naloxone, which reverses overdoses. I've been very
supportive of expanding access to naloxone for first responders.
Naloxone was administered at least 74,000 times in Ohio between 2003
and 2012. In 2014, alone, EMS treated 12,847 overdose patients with
naloxone.
I'm pleased to report that we've renewed our agreement with
Amphastar Pharmaceuticals, Inc.--a manufacturer of naloxone--to provide
rebates to consumers, such as police departments and other non-Federal
Government agencies that distribute the drug in Ohio. So far, 117 Ohio
agencies have applied for a total of $539,986.00 in rebates over the
past two years. Also, Adapt Pharma worked with my staff and agreed to
freeze the Public Interest Price over the next year for its naloxone
nasal spray for Ohio.
In 2015, the law changed in Ohio to allow pharmacies to sell
naloxone over the counter without a prescription. Since then, we worked
with several Ohio retail stores, including CVS, Kroger, and Walgreens,
who have agreed to sell naloxone. This also will help families and
friends who know someone who is addicted by letting them keep this
life-saving medication on-hand.
My office will continue to support families, schools, law
enforcement, the faith-based community, and others to bring hope and
healing to those who struggle with substance abuse and addiction. Thank
you again for the opportunity to testify today. I'm honored to be here
with the other witnesses and have the opportunity to hear about their
good work.
I'm happy to answer any questions at this time.
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Response to Question for the Record for Richard G. Frank From Senator
Klobuchar
importance of treatment
What would be the economic costs for communities if funding for
treatment from any of these programs was weakened?
The CDC estimates that the treatment cost of Opioid Use Disorder is
$28.9 billion and the overall cost to society is $78.5 billion in 2013.
Weakening funding would put new burden on communities for treatment
costs. But perhaps more importantly weakening funding would likely
reduce access to treatment. That would in turn increase other costs
associated with opioid use disorders like disability costs, child
welfare costs, and criminal justice costs among others.
__________
Responses to Questions for the Record for Richard G. Frank from Senator
Lee
How prevalent is Medicaid program abuse by addicts and dealers? Is
it more prevalent in certain parts of the country than others? Have any
states or communities found ways of fighting back or preventing this
potential risk?
In order to properly answer these questions it is important to put
the sources of prescription opioid misuse into context. The National
Household Survey on Drug Use and Health offers data on this issue. That
survey allows for the tracking of the sources of drugs that were
misused. Nearly 65% of misused prescription opioids were obtained from
family and friends (55% free and 9.9% via purchase), 5% were stolen
from family and friends. Roughly 17.6% were obtained through a
prescription and just under 5% were obtained from a drug dealer. So 70%
came from family and friends. All health care payment programs face the
challenge of diversion. This includes private health insurance,
Medicare, Medicaid, the VA, and the military health insurance programs.
As you know, the Affordable Care Act gave states new authority to
fight fraud and abuse related to drug diversion. This enables states to
take measures that focus on Medicaid but also on the range of insurers
and other payers.
Specifically the new authorities include:
Establish enhanced oversight for new providers.
Establish periods of enrollment moratoria or other limits
on providers identified as at high risk for fraud and abuse.
Establish enhanced provider screening.
Require states to suspend payment when there is a
credible allegation of fraud, which may include evidence of
overprescribing by doctors, over-utilization by recipients, or
questionable medical necessity.
The result has been that states have adopted a variety of
approaches aimed at stemming diversion of prescription opioids.
Kentucky has put into place a State-wide data base of all controlled
substances prescribed in the State. The Medicaid program has
effectively used that tool to identify aberrant prescribing and has
made investigations better targeted and more efficient. The State of
Pennsylvania has implemented a pro-active drug utilization review
process that targets drugs of abuse. Efforts in Florida and Oklahoma
have focused more specifically on pain management clinics for all
payers and have realized success in limiting diversions stemming from
``pill mills.'' States are also using so-called lock-in programs and in
some cases linking prescription drug monitoring programs to electronic
health records. Again these are not specifically aimed at Medicaid but
at all payers.
These efforts are meeting with some success as data reveal a
decline in the level of opioid prescribing. In sum, states are fighting
back and most of the efforts are aimed at prescribing broadly. Some of
these efforts are the result of new tools created for states, under the
Affordable Care Act.
__________
Responses to Questions for the Record for Richard G. Frank from Senator
Heinrich
medicaid cuts
1. What would happen to patients if their treatment for an opioid
addiction was interrupted because the patient no longer had coverage
for SUDs?
There are several results that emerge clearly from the literature
on treatment effectiveness that inform this question. First is that
Opioid Use Disorders are most effectively treated with Medication
Assisted Treatment or MAT. Second, is that receiving and remaining in
treatment with MAT reduces all cause overdose mortality. Third is that
the likelihood of a relapse increases significantly when MAT is
interrupted. In addition, relapse is associated with reduced functional
status, increased likelihood of family disruption, spread of infectious
disease, and contact with the criminal justice system.
2. Given that addiction is a lifelong disease, how would converting
Medicaid to a per capita cap hinder State efforts to address the long-
term health needs of people struggling with an SUD?
The consensus in the scientific community as recently summarized by
the Surgeon General of the United States is that addictions generally
and opioid use disorder specifically are chronic relapsing diseases of
the brain. These illnesses also co-occur with a variety of other
medical problems and chronic illnesses (depression, HIV, hepatitis C).
The result is that the average cost of treating someone with an opioid
use disorder in Medicaid is on the order of $11,000 to $12,000 per year
compared to $3,000 to $4,000 for the average Medicaid recipient. A per
capita cap changes the incentives to the states. Currently states
receive matching payments from the Federal Government so that Federal
payments increase with State spending increases. The per capita cap
would change the incentives in that increased State spending would not
longer be met with higher Federal payments, thereby rewarding
aggressive cost cutting. One of the easiest ways to cut costs is to
avoid the sickest people and enroll the healthiest. This is easy to do,
especially with people suffering from a substance use disorder. That
is, because these illnesses require outreach and on-going support to
engage and retain them in treatment. Curtailing such activities will
reduce participation in Medicaid for people with SUDs. Thus because
people with an opioid use disorder are much more costly than the
average Medicaid enrollee, the incentives suggest that we would likely
encounter less outreach and engagement activities in Medicaid and less
aggressive follow-up efforts to retain people in treatment.
3. How would converting Medicaid to a per capita cap impact a
State's ability to cover treatments for these co-occurring conditions?
In my answer to #2 above I touch on the basic economics that are at
work in serving people with costly co-occurring conditions. In addition
to the issues raised in that response, there is the matter of what
happens when the population with addictions and co-occurring diseases
is growing in size. There is a great deal of evidence indicating that
the opioid use epidemic is growing. Recent evidence on emergency room
growth and hospital use for opioid use disorders shows they have been
growing at annual rates of 5.7% and 8%, respectively. Mortality from
OUD has been increasing at roughly 9% per year since 1979 and at about
15% in recent years and prescribing of MAT drugs has grown rapidly as
well. For this reason people with opioid use disorder can be expected
to make increasing claims on the health care system and Medicaid. A per
capita cap would lock in spending patterns using 2016 as the baseline
and then increase Federal payments by either CPI or CPI-M. Thus the
proposed growth in Federal payments is forecasted by CBO to be at 3.7%
(CPI-M) or less. This heightens the incentives to avoid people with
these illnesses that I described earlier.
4. How important is treating these conditions to supporting a
person's long-term recovery?
Addictions and opioid use disorders specifically frequently are
intertwined with mental health problems and other medical issues. For
example, an estimated 30% of people with an opioid use disorder are
also depressed. Misuse of drugs has been linked to self-medication for
mental illnesses and pain. Thus, having coverage for the range of
health needs is critical for populations that suffer from complex
arrays of mental, addictive and other medical conditions.
5. Would this one-time investment sufficiently offset the harm the
underlying bill would do to millions of Americans with SUDs?
The $15 billion proposed in the AHCA to address mental health SUD
and maternity care needs would not come close to compensating for the
funding cuts that would result from package of coverage reductions in
the AHCA. Let me illustrate with some relevant data. There are about
220,000 people with an opioid use disorder and an additional 1.2
million people with a serious mental illness that are currently covered
through the Medicaid expansion and the Health Insurance Marketplaces.
In addition, there are 713,000 people with an opioid use disorder with
incomes below the poverty line, many of who are uninsured. Data
collected from State Medicaid programs noted earlier indicate that
today it costs about $11,000 per person to treat someone with a serious
mental illness or an opioid use disorder. If states apply all those
funds only to people with these serious illnesses in the Medicaid
expansion and Health Insurance Marketplaces, that would make up 1.42
million people. If we make the conservative assumption that these
individuals only use services in two out of the next five years, the
total cost would exceed $31 billion. This cost would exhaust these
funds even assuming every dollar were spent only on such services for
such individuals rather than all those who qualify. Thus, the new money
added to the AHCA would fall short making up for the bill's reduced
coverage of people with the most serious mental and addictive
conditions let alone other conditions.
__________
Responses to Questions for the Record for Lisa Sacco from Senator Mike
Lee
This memorandum responds to two questions submitted by Vice
Chairman Mike Lee for the Joint Economic Committee Hearing, ``The
Economic Aspects of the Opioid Crisis'':
How have different states adapted their justice systems
to deal with the opioid crisis?
What impact have drug courts had?
While the information below is tailored to your specific questions,
portions of it may be included in other Congressional Research Service
products available to other Members of Congress. If you have any
additional questions, please do not hesitate to contact me.
How have different states adapted their justice systems to deal
with the opioid crisis?
Across the country, states have dealt with rising death rates
linked to opioid overdoses. In response, they have adapted certain
elements of their criminal justice responses--including police, court,
and correctional responses \1\--in a variety of ways. While this
response does not provide a State-by-State analysis, it highlights
several examples of how States' justice systems have responded to the
opioid crisis.
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\1\ Not all states respond by adapting every component of the
criminal justice system.
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One of the more widespread responses is increasing law enforcement
officer access to naloxone, an opioid overdose reversal drug.\2\
Officers receive training on how to identify an overdose and administer
naloxone, and they carry the drug to be able to immediately respond to
an overdose. As of December 2016, over 1,200 police departments in 38
states had officers that carry naloxone.\3\ In addition, most states
that have expanded access to naloxone have also provided immunity to
those who possess, dispense, or administer the drug. Generally,
immunity entails legal protections from arrest or prosecution and/or
civil suits for those who prescribe or dispense naloxone in good
faith.\4\
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\2\ National Conference of State Legislatures, Drug Overdose
Immunity and Good Samaritan Laws, June 5, 2017, http://www.ncsl.org/
research/civil-and-criminal-justice/drug-overdose-immunity-good-
samaritan-laws.aspx.
\3\ See North Carolina Harm Reduction Coalition (NCHRC), Law
Enforcement Departments Carrying Naloxone, http://www.nchrc.org/law-
enforcement/us-law-enforcement-who-carry-naloxone/.
\4\ Some laws also provide disciplinary immunity for medical
professionals.
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Another criminal justice adaptation is the enactment of what are
known as ``Good Samaritan'' laws to encourage individuals to seek
medical attention (for themselves or others) related to an overdose
without fear of arrest or prosecution. For example, this immunity would
prevent criminal prosecution for illegal possession of a controlled
substance in certain states and under specified circumstances. While
these laws vary by State as to what offenses and violations are
covered, as of June 2017, forty states and the District of Columbia
have some form of Good Samaritan overdose immunity laws.\5\
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\5\ National Conference of State Legislatures, Drug Overdose
Immunity and Good Samaritan Laws, June 5, 2017, http://www.ncsl.org/
research/civil-and-criminal-justice/drug-overdose-immunity-good-
samaritan-laws.aspx.
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Most states have drug diversion or drug court programs \6\ for
criminal defendants with substance abuse issues including opioid
abuse.\7\ Some states view drug courts as a tool to address rising
opioid abuse and have moved to further expand drug court options in the
wake of the opioid epidemic. In August 2016, representatives from
several states that have been confronted with high opioid overdose
death rates \8\ convened for the Regional Judicial Opioid Summit. Part
of these states' action plans to address opioid abuse was to expand
drug courts and other court diversion and sentencing options that
provide substance-abuse treatment and alternatives to incarceration.\9\
Further, in April 2017, the National Governors Association announced
that eight states would participate in a ``learning lab'' to develop
best practices for dealing with opioid abuse treatment for justice-
involved populations--including the expansion of opioid addiction
treatment in drug courts.\10\
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\6\ Some specialized court programs are designed to divert certain
defendants and offenders away from traditional criminal justice
sanctions such as incarceration while reducing overall costs and
helping these defendants and offenders with substance abuse issues.
Drug court programs may exist at various points in the justice system,
but they are often employed post-arrest as an alternative to
traditional criminal justice processing. For more information, see CRS
Report R44467, Federal Support for Drug Courts: In Brief, by Lisa N.
Sacco.
\7\ National Governors Association, States Expand Opioid Addiction
Treatment in Drug Courts, Corrections, April 11, 2017, https://
www.nga.org/cms/news/2017/states-expand-opioid-addiction-treatment. For
more information, see CRS Report R44467, Federal Support for Drug
Courts: In Brief, by Lisa N. Sacco.
\8\ These states include Kentucky, Illinois, Indiana, Michigan,
Ohio, Pennsylvania, Tennessee, Virginia, and West Virginia.
\9\ Michelle White and Tara Kunkel, National Center for State
Courts, ``Opioid Epidemic and the Courts,'' Trends in State Courts,
2017, http://www.ncsc.org.
\10\ National Governors Association, States Expand Opioid Addiction
Treatment in Drug Courts, Corrections, April 11, 2017, https://
www.nga.org/cms/news/2017/states-expand-opioid-addiction-treatment.
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Further, in recent years, several states have enacted legislation
increasing access to medication-assisted treatment for drug-addicted
offenders who are incarcerated or have recently been released.\11\
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\11\ National Conference of State Legislatures, American Epidemic:
Overdose on Opioids, State Legislatures Magazine, April 2016, http://
www.ncsl.org/bookstore/state-legislatures-magazine/overdosed-on-
opioids.aspx.
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What impact have drug courts had?
Drug courts are specialized court programs that present an
alternative to the traditional court process for certain criminal
defendants and offenders. Traditionally, these individuals are first-
time, nonviolent offenders who are known to abuse drugs and/or alcohol.
While there are additional specialized goals for different types of
drug courts, the overall goals of adult and juvenile drug courts are to
reduce recidivism and substance abuse.\12\
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\12\ For more information, see CRS Report R44467, Federal Support
for Drug Courts: In Brief, by Lisa N. Sacco.
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Drug court programs may exist at various points in the justice
system, but they are often employed post-arrest as an alternative to
traditional criminal justice processing. Any drug courts, including
some Federal drug court programs, are actually reentry programs that
assist a drug-addicted convict in reentering the community while
receiving treatment for substance abuse.
While drug courts vary in composition and target population, they
generally have a comprehensive model involving
offender screening and assessment of risks and needs,
judicial interaction,
monitoring (e.g., drug and alcohol testing) and
supervision,
graduated sanctions and incentives, and
treatment and rehabilitation services.\13\
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\13\ U.S. Department of Justice, National Institute of Justice,
Drug Courts, March 2015, http://www.nij.gov/topics/courts/drug-courts/.
Drug courts are typically managed by a team of individuals from (1)
criminal justice,\14\ (2) social work, and (3) treatment service.\15\
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\14\ Including judges, prosecutors, defense attorneys, and
community corrections officers.
\15\ U.S. Department of Justice, Office of Justice Programs, Drug
Courts, June 2015, https://www.ncjrs.gov/pdffiles1/nij/238527.pdf.
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Jurisdictions have sought to utilize drug courts in efforts to
treat individuals' drug addictions, lower recidivism rates for drug-
involved offenders, and lower costs associated with incarcerating these
offenders. Since the inception of drug courts, a great deal of research
has been done to evaluate their effectiveness and their impact on
offenders, the criminal justice system, and the community. Much of the
research yields positive outcomes.\16\
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\16\ U.S. Department of Justice, National Institute of Justice
(NIJ), Do Drug Courts Work? Findings from Drug Court Research, http://
www.nij.gov/topics/courts/drug-courts/Pages/work.aspx; Douglas B.
Marlowe, Painting the Current Picture: A National Report on Drug Courts
and Other Problem-Solving Court Programs in the United States, June
2011, http://www.ndci.org/sites/default/files/nadcp/
PCP%20Report%20FINAL.PDF.
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Several studies have demonstrated that drug courts may lower
recidivism rates and lower costs for processing offenders compared to
traditional criminal justice processing.\17\ One group of researchers
examined the impact of a drug court over 10 years and concluded that
treatment and other costs associated with the drug court (investment
costs) \18\ per offender were $1,392 less than investment costs of
traditional criminal justice processing. In addition, savings due to
reduced recidivism for drug court participants were more than $79
million over the 10-year period.\19\ A collaboration of researchers
conducted a five-year longitudinal study of 23 drug courts from several
regions of the United States and reported that drug court participants
were significantly less likely than nonparticipants to relapse into
drug use and participants committed fewer criminal acts than non-
participants after completing the drug court program.\20\
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\17\ Steven Belenko, ``Research on Drug Courts: A Critical
Review,'' National Drug Court Institute Review, vol. 1, no. 1 (June
1998), pp. 15-16.
\18\ These include costs associated with arrest, booking, court,
jail, and probation.
\19\ Michael W. Finigan, Shannon M. Carey, and Anton Cox, The
Impact of a Mature Drug Court over 10 Years of Operation: Recidivism
and Costs, NPC Research, Final Report, April 2007.
\20\ For a summary of and various publications discussing the
Multisite Adult Drug Court Evaluation funded by NIJ and conducted by
the Urban Policy Institute, Justice Policy Center, RTI International,
and the Center for Court Innovation, see http://www.nij.gov/topics/
courts/drug-courts/Pages/madce.aspx.
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Still, some are skeptical of the impact of drug courts. The Drug
Policy Alliance \21\ has claimed that drug courts help only offenders
who are already expected to do well and do not truly reduce costs. This
organization also has criticized drug courts for punishing addiction
because drug courts dismiss those who are not able to abstain from
substance use.\22\
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\21\ The Drug Policy Alliance is a national advocacy group that
advocates for drug law reform.
\22\ Drug Policy Alliance, Drug Courts are Not the Answer: Toward a
Health-Centered Approach to Drug Use, March 2011, https://
www.drugpolicy.org/docUploads/Drug--Courts--Are--Not--the--Answer--
Final2.pdf.
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__________
Questions for the Record for Hon. Mike DeWine Submitted by Senator Amy
Klobuchar
state treatment programs
Attorney General DeWine--Two weeks ago, I participated in a hearing
at the Senate Permanent Subcommittee on Investigations on ``Stopping
the Shipment of Synthetic Opioids: Oversight of U.S. Strategy to Combat
Illicit Drugs.'' At that hearing the Policy Chief from Newtown, Ohio,
testified on the importance of Medicaid when it comes to fighting this
epidemic.
How much funding does the State of Ohio annually spend to
reduce drug abuse and overdose deaths?
I would refer you to the Ohio Office of Budget and Management for
specific figures. The figures from OBM may not necessarily include
dollars spent locally on the epidemic for items such as recovery
services, support of law enforcement programs, coroner and funeral
services, hospice care, the cost to business, costs related to
increased crime, and medical care. In my office, we fund numerous
efforts to support law enforcement such as lab services, technical
equipment, and investigation support. We also provide funding for
specialized programs to address the needs of children in the child
welfare system and to address drug abuse education in schools.
How much of this funding comes from Medicaid--both as a
percentage and in total?
I would refer you to the Ohio Office of Budget and Management for
specific figures.
How would you expect the elimination of the Medicaid
expansion program to affect the ability of Ohio to continue fighting
the opioid epidemic and the increasing treatment gaps that you
mentioned during your testimony?
Medicaid expansion has allowed many Ohioans to establish and
maintain access to mental health and addiction services. Reductions in
Medicaid would reduce Ohioans' access to treatment services needed to
recover from addiction.
__________
Questions for the Record for Attorney General DeWine Submitted by
Senator Mike Lee
Attorney General DeWine--Federal and State policymakers have not
always responded in the most prudent or humane way in response to past
drug epidemics. We have made some grave errors, some of which are
reflected in today's criminal code, for example. Given the wide-ranging
expertise you bring to bear on these issues, what, in your view, is the
most important mistake for us to avoid as we craft policy addressing
this epidemic?
It is very important to always include different perspectives by
those who are affected by the opioid crisis. For example, hearing from
medical professionals, first responders, and individuals in recovery is
very important. Considering the diversity among counties is also
critical. A solution in a rural community may be vastly different from
a solution in an urban community. We have been very fortunate to work
on a grass roots level so that when programming is crafted it is done
so that it fits who and where it was designed for.
The Federal Government and State governments obviously play
important roles in combating the opioid crisis. But I'm particularly
interested in what local communities and voluntary organizations are
doing on this front. Can you point to any examples of local
organizations or initiatives in Ohio that have been successful in
helping people overcome opioid addiction?
Throughout the State of Ohio, numerous communities have implemented
programs and services that have made a positive difference. One of the
examples can be found in Pickaway County, just south of Columbus.
Pickaway County has an Addiction Council that is comprised of
approximately 60 individuals from a cross section of the community.
Since their inception, they have developed an excellent website
(https://www.drugfreepickaway.com/) and social media page, held
numerous awareness and assistance events, produced a Parent Guide that
has been distributed to approximately 3,000 parents, implemented drug
prevention programming in the schools in addition to DARE, trained law
enforcement on how to administer naloxone and how to better investigate
an overdose scene, changed the approach in the judicial system, and
designed a program in the jail that has reduced recidivism.
The jail program is an excellent example of how lives can be
changed by community collaboration. The Pickaway County jail was
crowded to overcapacity and the same people continued to cycle through.
The jail administrator set up a program that has reduced the recidivism
rate and led to a decline in the jail population.
Upon release an inmate has the opportunity to receive Vivitrol. To
have this opportunity, the inmate must complete a questionnaire asking
them how they plan to remain drug free. If the inmate is approved, a
judge is asked to grant that the inmate will be released to a nearby
treatment facility. Job and Family Services signs the inmate up for
Medicaid the day of release. If the inmate and the team agree that
additional help may be needed, the Sheriff's Office reaches out to a
church who will have a member walk alongside the inmate upon release.
The inmate is also provided a packet of information about a variety of
support services. No additional dollars were needed for this program.
My office held our first faith conference in March of 2015. We have
held seven faith conferences across the State with two in conjunction
with the West Virginia Attorney General's Office. We have worked very
closely with the faith community to develop ``champions'' across the
State. Champions are individuals within a faith community who have been
trained on how to provide support to those with the disease of
addiction and to their families. We now have almost 200 champions
across the State. These champions and others from the faith community
have held events, provided resources, visited families after the
overdose of a loved one, worked with law enforcement on their outreach
efforts, provided a place of safety and comfort, and opened recovery
homes.
I and others are concerned about the state of social capital in
America--the strength of our associational life and our connectedness
to each other. A recent study published in the journal Drug and Alcohol
Dependence found that counties across America with lower social capital
also generally have higher drug overdose rates. The findings suggest
that tight-knit communities possess a greater resiliency to drug
epidemics. I would be interested to hear your thoughts as to the
importance of healthy social relationships and a thriving civil society
in mitigating the threat of the opioid crisis.
I agree with Sam Quinones, author of Dreamland, who refers to the
disease of addiction as a disease of isolation. He stated that as the
addition progresses, the person affected and often their family become
isolated in their home (due to stigma and lack of services).The
addicted individual remains isolated through their addiction and,
unfortunately, the end result may be death.
We know that this epidemic has caused stress in our communities,
leading to the destruction of families, the economic impact, and the
compassion fatigue of those overwhelmed by what they have experienced.
But there is hope. When communities come together, stigma declines
and people feel supported in their journeys to recovery. We hear from
those in recovery that they need places to go where they can be with
others in recovery, not a treatment center or a recovery home. They
need, as do many others, a place where they can build healthy social
relationships and once again contribute to society.
__________
Question for the Record for Professor Deaton Submitted by Senator Mike
Lee
Professor Deaton--In your research you've noted a connection
between, on the one hand, low rates of marriage and high family
instability among working-class whites and, on the other hand, ``deaths
of despair.'' Can you describe some of these trends in family
instability and discuss how they may have played a role in the opioid
epidemic?
Thank you, Senator Lee. It is a good question, and one to which, at
this stage, we have only partial answers and a good deal of
speculation. In my work with Anne Case, we have followed the findings
of a number of sociologists and political scientists who have
identified a long-term increase in dysfunctional family behaviors,
particularly among those who do not have a university degree. Marriage
rates are falling, and cohabitations are rising. Cohabitations often
come with out-of-wedlock births. Cohabitations in the U.S. are
unstable, at least compared with Europe, so many dads do not live with,
or even know their kids, and many kids have many ``father'' figures,
who are not their fathers. There is good evidence that one cause,
though not the only one, is progressive failure in the labor market,
where, for those without a BA, good, committed, long-term jobs with
prospects have become ever scarcer, and where real earnings have not
risen for 40 years. Other dysfunctions that have increased in parallel
include withdrawal from the labor force, increased social isolation,
and a range of morbidities, including physical pain. Many men and women
without a BA, when they reach middle age, feel that their lives have
failed; they have done worse than their parents, and they are missing
the meaning and satisfaction that a good career and a good family life
brings to people in late middle-age. This raises the risk of suicide,
of alcoholism, and the susceptibility to other addictions. Addictions,
in turn, undermine family life and the ability to work. We think of
opioids--both legal and illegal--as having thrown fuel on the flames,
and they greatly aggravated a crisis that was already there. Of course,
we do not claim that opioids are not incredibly dangerous on their own,
nor that legal and illegal drug dealing is not reprehensible. As the
example of Utah shows, a good family life and a supportive church may
not protect people against over-enthusiastic physicians. But we believe
that the slow erosion of white working class life has predisposed
people to the epidemic.
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