[Senate Hearing 115-684]
[From the U.S. Government Publishing Office]


                                                    S. Hrg. 115-684

      PREVENTING AND TREATING OPIOID MISUSE AMONG OLDER AMERICANS

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

                                HEARING

                               BEFORE THE

                       SPECIAL COMMITTEE ON AGING

                          UNITED STATES SENATE

                     ONE HUNDRED FIFTEENTH CONGRESS


                             SECOND SESSION

                               __________

                             WASHINGTON, DC

                               __________

                              MAY 23, 2018

                               __________

                           Serial No. 115-18

         Printed for the use of the Special Committee on Aging
         
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

        Available via the World Wide Web: http://www.govinfo.gov


                               __________
                               

                    U.S. GOVERNMENT PUBLISHING OFFICE                    
35-282 PDF                  WASHINGTON : 2019                     
          
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                       SPECIAL COMMITTEE ON AGING

                   SUSAN M. COLLINS, Maine, Chairman

ORRIN G. HATCH, Utah                 ROBERT P. CASEY, JR., Pennsylvania
JEFF FLAKE, Arizona                  BILL NELSON, Florida
TIM SCOTT, South Carolina            KIRSTEN E. GILLIBRAND, New York
THOM TILLIS, North Carolina          RICHARD BLUMENTHAL, Connecticut
BOB CORKER, Tennessee                JOE DONNELLY, Indiana
RICHARD BURR, North Carolina         ELIZABETH WARREN, Massachusetts
MARCO RUBIO, Florida                 CATHERINE CORTEZ MASTO, Nevada
DEB FISCHER, Nebraska                DOUG JONES, Alabama

                              ---------- 
                              
                 Kevin Kelley, Majority Staff Director
                  Kate Mevis, Minority Staff Director
                  
                                CONTENTS

                              ----------                              

                                                                   Page

Opening Statement of Senator Susan M. Collins, Chairman..........     1
Statement of Senator Robert P. Casey, Jr., Ranking Member........     3

                           PANEL OF WITNESSES

Gary Cantrell, Deputy Inspector General for Investigations, 
  Office of Inspector General, Department of Health and Human 
  Services.......................................................     5
Charles Pattavina, M.D., FACEP, Medical Director and Chief of 
  Emergency Medicine, St. Joseph Hospital, Bangor, Maine.........     7
William Stauffer, Executive Director, Pennsylvania Recovery 
  Organizations Alliance.........................................     8
Nicolas P. Terry, Professor of Law and Executive Director of the 
  William S. and Christine S. Hall Center for Law and Health, 
  Indiana University.............................................    10

                                APPENDIX
                      Prepared Witness Statements

Gary Cantrell, Deputy Inspector General for Investigations, 
  Office of Inspector General, Department of Health and Human 
  Services.......................................................    28
Charles Pattavina, M.D., FACEP, Medical Director and Chief of 
  Emergency Medicine, St. Joseph Hospital, Bangor, Maine.........    38
William Stauffer, Executive Director, Pennsylvania Recovery 
  Organizations Alliance.........................................    42
Nicolas P. Terry, Professor of Law and Executive Director of the 
  William S. and Christine S. Hall Center for Law and Health, 
  Indiana University.............................................    46

 
      PREVENTING AND TREATING OPIOID MISUSE AMONG OLDER AMERICANS

                              ----------                              


                        WEDNESDAY, MAY 23, 2018

                                       U.S. Senate,
                                Special Committee on Aging,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 1:59 p.m., in 
room SD-562, Dirksen Senate Office Building, Hon. Susan M. 
Collins, Chairman of the Committee, presiding.
    Present: Senators Collins, Casey, Gillibrand, Blumenthal, 
Donnelly, and Cortez Masto.

    OPENING STATEMENT OF SENATOR SUSAN M. COLLINS, CHAIRMAN

    The Chairman. The hearing will come to order.
    Good afternoon. First, let me thank our witnesses for 
rearranging their schedules this afternoon to be here even 
earlier than we had anticipated. We are going to have a series 
of votes beginning at 3:15, so we wanted to move up the time of 
the hearing.
    Last year, the Portland Press Herald ran an in-depth series 
titled ``Lost,'' which told the stories of Mainers who had been 
most affected by the opioid epidemic. The stories highlighted 
and exposed many, often unseen, facets of this crisis. It made 
clear that no one is immune from the devastating effects of 
addiction.
    Dr. Mary Dowd, who specializes in addiction treatment and 
sees hundreds of patients through her work at Catholic 
Charities Maine, told the newspaper, ``I still think people 
have this idea in their head about who is caught up in this 
crisis. It could be anyone.''
    Many perceive the face of opioid addiction as young. 
Indeed, I met this very morning with a substantial group of 
young people from Maine called Young People in Recovery who 
were representing young adults from our state who are in 
recovery or working with those who are seeking to be part of 
the recovery community.
    This epidemic, however, intersects just as much with older 
adults, something that I think has not received the focus that 
it deserves. According to the Inspector General, one in three 
Medicare Part D beneficiaries received an opioid prescription 
in 2016. The Centers for Disease Control estimates that the 
number of people age 55 or older treated in emergency rooms for 
opioid overdoses increased by nearly a third from 2016 to 2017.
    Treating pain effectively in an environment where abuse of 
prescription painkillers is rampant remains a concern for 
clinicians. Nearly half of older Americans suffer from chronic 
pain, and the incidence increases with age.
    In addition to the risk of addiction, older adults taking 
opioids are also four to five times more likely to fall than 
those taking non-steroidal, anti-inflammatory drugs.
    Regrettably, health care providers sometimes miss substance 
abuse among older adults, as the symptoms can be similar to 
depression or dementia.
    Alternatives to opioids are critical, yet those 
alternatives may also be more expensive and less convenient for 
patients. For example, physical therapy can benefit patients 
suffering from pain, support long-term recovery, and stave off 
the need for medication, yet patients who work may not have the 
flexibility to leave their jobs for regular physical therapy 
appointments. Repeated travel can also be a substantial hurdle 
for some patients, particularly during the winter months or 
when a medical condition makes driving unsafe.
    Challenges in treatment and recovery persist as well. 
Seniors in need of treatment may face serious obstacles to 
accessing care due to a shortage of geriatric health 
professionals as well as behavioral health care professionals.
    In rural areas, those obstacles may be worsened. While 
there is no silver bullet to ending this epidemic, Congress and 
this Committee are fighting back on multiple fronts. Since our 
hearing on opioid use and abuse two years ago, we have made 
progress in how health care providers discuss pain with their 
hospitalized patients. At that hearing, I questioned whether 
hospital performance surveys could be contributing to the vast 
supply of prescription opioids in circulation by penalizing 
hospitals if physicians, in their best medical judgment, opted 
to limit opioid pain relievers to certain patients.
    CMS concurred, and since last January, surveys are now 
asking patients three questions that address communication 
about pain during their hospital stay, rather than pain 
management. For example, patients used to be asked a question 
that I really thought was egregious. It was ``How often did the 
hospital staff do everything they could to help you with your 
pain?'' Now patients are being asked ``How often did hospital 
staff talk with you about how to treat your pain?'' Big 
difference.
    Since our hearing, Congress also passed the Comprehensive 
Addiction and Recovery Act, or CARA, as well as the 21st 
Century Cures Act, and the recent budget agreement contained $6 
billion to address the opioid crisis.
    Last year, HHS issued more than $800 million in grants to 
support access to opioid-related treatment, prevention, and 
recovery, while making it easier for states to receive waivers 
to cover treatment through their Medicaid programs.
    I remain concerned, however, that at least in some areas, 
it is taking far too long for those funds to reach local health 
care providers, treatment and recovery organizations, and 
groups and schools involved with prevention and education 
efforts.
    I have authored two bills to further address this epidemic 
that have been included in the recent HELP Committee opioids 
package. The Safe Disposal of Unused Medication Act would 
authorize certain hospice employees to dispose of controlled 
substances in a patient's residence after the hospice patient 
dies. This would reduce the dangerous risk of diversion of 
unused painkillers.
    Another bill, the Opioid Peer Support Networks Act, would 
authorize grants to support the creation of peer support 
networks and create a national technical assistance center to 
provide the resources and training to help them be successful.
    Through these networks, those battling addiction support 
one another on the road to long-term recovery. So this bill 
addresses a gap in recovery care since, currently, an estimated 
40 to 60 percent of recovering addicts relapse.
    And just last week, the FDA approved the first non-opioid 
treatment for the management of opioid withdrawal symptoms in 
adults. Greater innovation in this area as well as the 
development of more non-opioid painkillers is crucial, and I 
commend FDA Commissioner Gottlieb for his leadership.
    While all of these steps represent progress, we must 
continue to reexamine this issue from every angle, as the 
opioid crisis continues to tighten its grip not only on older 
adults, but also on future generations.
    I now look forward to hearing from our witnesses, but 
first, I turn to our Ranking Member, Senator Casey, for his 
opening statement.
    Thank you, Senator.

  OPENING STATEMENT OF SENATOR ROBERT P. CASEY, JR., RANKING 
                             MEMBER

    Senator Casey. Thank you, Madam Chairman, for holding this 
hearing today on this critically important topic.
    When I ask the people of Pennsylvania how opioids affect 
their families, I am met with--and I know this goes for every 
Senator who goes home to talk about these issues. I am met with 
one too many harrowing stories, over and over again, story 
after story.
    One of the worst stories, probably the worst story or the 
most telling metric unfortunately, was something that a coroner 
in one of our counties said to me last summer, back in August, 
when we went around the state, county after county, dealing 
with this horror. He told me that because of opioid overdoses, 
he had run out of places to put the bodies. Too many bodies 
were coming in every night, and there was no place to put them, 
literally running out of space. More than any other story, this 
one underscores the urgent need for Congress to continue to 
take aggressive action.
    The opioid epidemic is ravaging our communities, and I am 
not sure that adequately describes it. It is in every corner of 
our country, from small, rural towns to bustling city centers 
and even to suburbs. It affects people of all ages, from tiny 
little babies to aging grandparents.
    Recently, ``60 Minutes'' told the story of how grandparents 
across the country are ``saving a generation'' by stepping up 
to raise their grandchildren. I think that is why we have a 
responsibility to save these multiple generations.
    That is why I introduced legislation to provide $45 billion 
in federal support to support community programs to detect, 
prevent, and treat opioid misuse, and that is why I am working 
with Chairman Collins to make sure that grandparents raising 
their grandchildren, whose parents are lost to opioids, know 
where to turn for both education and support.
    It is also why I have been working on a bipartisan basis 
with Leader McConnell to create a federal plan to provide 
opioid treatment for infants as well as to pregnant and 
postpartum women.
    And I have also worked with Senator Portman so that older 
Americans and people with disabilities have Medicare coverage 
for the opioid treatment that is right for them.
    I was pleased to join Democrats and Republicans in 
providing $6 billion to states to fund prevention, treatment, 
and recovery efforts over the next two years, but I know that 
is not enough. Nearly 13 Pennsylvanians are lost every day due 
to a drug overdose, beyond the opioid issue but substance use 
disorder overall.
    We have to do more for every generation, and we have to do 
it now.
    Older Americans are among those unseen in this epidemic. In 
2016, one in three people with a Medicare prescription drug 
plan received an opioid prescription. This puts baby boomers 
and our oldest generation at great risk.
    More than 1,400 older adults lost their lives to opioids in 
2016--1,400 people--despite the availability of life-saving 
medications that reverse overdose. These startling facts beg 
the question: What more should we be doing? What barriers 
prevent older Americans from accessing treatment? What more can 
Congress do to ensure that not one more senior goes without 
recovery services?
    For instance, I am exploring how to make opioid treatment 
more affordable. A high copayment should not stand between a 
senior who needs treatment and their access to care.
    It is time for bold and bipartisan leadership to address 
the wreckage of this dreadful epidemic. Indeed, this hearing is 
an important step in doing just that, and I want to thank 
Chairman Collins again and look forward to our witnesses' 
testimony.
    The Chairman. Thank you very much, Senator Casey.
    I am pleased to introduce our witnesses. Our first witness 
is Gary Cantrell, the Deputy Inspector General for 
Investigations at the Department of Health and Human Services, 
Office of the Inspector General.
    Mr. Cantrell will provide an overview of the Office of 
Inspector General's report, ``Opioids in Medicare Part D: 
Concerns About Extreme Use and Questionable Prescribing.''
    Next, I am delighted to introduce Dr. Charles Pattavina, 
the Medical Director and Chief of Emergency Medicine at St. 
Joseph Hospital in Bangor, Maine. He is also former president 
of the Maine Medical Association. Dr. Pattavina has extensive 
experience treating patients in the State of Maine, including 
adults living with debilitating chronic pain. And I want to 
thank you personally for taking the time of what I know 
firsthand is a very busy schedule serving patients.
    I will now turn to our Ranking Member to introduce our 
witness from the Commonwealth of Pennsylvania.
    Senator Casey. Thank you, Madam Chairman.
    I am pleased to introduce William Stauffer, who is a 
lifelong Pennsylvanian and resident of Allentown in the Lehigh 
Valley on the eastern side of our state, and I know we have met 
before along the road, but I did not have a chance to 
personally welcome you to the hearing today. I was running 
late. So thanks for being here.
    Mr. Stauffer's organization, the Pennsylvania Recovery 
Organizations Alliance, represents community-based groups, 
family support programs, and advocates across the state working 
tirelessly to promote treatment for substance use disorders. He 
has more than 25 years' experience offering counseling and 
administrative support to recovery programs. He brings a very 
personal lens to our hearing today, as he is in long-term 
recovery.
    Mr. Stauffer, as a social worker, I am especially proud to 
have you here today for that and many reasons. The social work 
profession is near to my heart. My daughter is a social worker. 
I know what you bring to your work and what it means to so 
many. We are fortunate to have your perspective today both as a 
recovery professional as well as a person living with an 
addiction.
    Thank you again for being here. We look forward to your 
testimony.
    The Chairman. Mr. Terry, I know that Senator Donnelly very 
much wants to introduce you and that he is on his way. So I am 
going to turn to Mr. Cantrell for his testimony, and it is not 
that you are being neglected. It is that your home state 
Senator is very proud of you and wants to introduce you 
personally.
    So, Mr. Cantrell.

   STATEMENT OF GARY CANTRELL, DEPUTY INSPECTOR GENERAL FOR 
  INVESTIGATIONS, OFFICE OF INSPECTOR GENERAL, DEPARTMENT OF 
                   HEALTH AND HUMAN SERVICES

    Mr. Cantrell. Good afternoon, Chairman Collins, Ranking 
Member Casey, and Senators Cortez Masto and Senator Blumenthal. 
I appreciate the opportunity to be here today to speak with you 
about OIG's efforts to combat the opioid epidemic in federal 
health care programs.
    Given our long history of health care fraud enforcement, 
program oversight, and data analytic capabilities, OIG is 
uniquely positioned to help lead the fight against illegal 
opioid prescribing in Medicare and Medicaid, and we are also 
intent on using our resources to assist HHS in delivering 
quality treatment services to those in need.
    Opioid-related fraud encompasses a broad range of criminal 
activity, from prescription drug diversion to addiction 
treatment fraud. Many of these schemes involve kickbacks, 
medical identity theft, and criminal enterprises. The 
development of our investigations into these schemes is 
complex, requiring the full range of law enforcement techniques 
to gather evidence of crimes, often committed by corrupt 
doctors, pharmacists, and criminal networks.
    In the worst cases, our special agents have uncovered 
evidence of illegal prescribing resulting in deaths from 
overdose.
    Given the complexity and high stakes of these 
investigations, OIG's partnership with DOJ, FBI, DEA, and state 
Medicaid fraud control agencies are critical to the success of 
our efforts.
    OIG and our Medicare Fraud Strike Force partners led the 
2017 National Health Care Fraud Takedown. This enforcement 
operation brought together more than 1,000 federal and state 
law enforcement personnel, including 350 OIG special agents. 
The 2017 takedown was the largest health care fraud enforcement 
action ever, resulting in over 400 charged defendants across 
the country. 120 of these defendants were charged for their 
roles in illegally prescribing opioids and other dangerous 
narcotics.
    OIG has also shifted resources to support the Attorney 
General's Opioid Fraud and Abuse Detection Unit, a multi-agency 
effort capitalizing on data analytics. Prosecutors and agents 
currently operate in 12 districts and focus solely on 
investigating and prosecuting opioid-related health care fraud.
    OIG uses advanced data analytics to put timely actionable 
information about prescribing, billing, and utilization trends 
in the hands of investigators, auditors, evaluators, and our 
government partners.
    Our July 2017 data brief identified Medicare beneficiaries 
receiving extremely high amounts of opioids, and questionable 
prescribing demonstrates the value of this approach. Of note, 
the report uncovered that half a million Medicare beneficiaries 
received opioids well in excess of CDC guidelines. Of 
particular interest to this Committee, 36 percent of these 
beneficiaries were age 65 or older.
    Further, nearly 90,00 beneficiaries are at serious risk of 
opioid misuse or overdose. Some received extreme amounts of 
opioids, over two and a half times the CDC guidelines, while 
others appeared to be doctor shopping, and 23 percent of these 
beneficiaries were age 65 or older.
    To get at the source of this extreme use, OIG identified 
about 400 prescribers, with questionable opioid prescribing for 
these beneficiaries who are at serious risk, and we are 
following up on these outlier prescribers and have also shared 
this data with our public-and private-sector partners.
    OIG will also release an update to this data brief later 
this summer based on more recent claims data. This update will 
help us monitor trends in opioid prescribing and direct our 
resources where most needed.
    In conjunction with the new data brief, OIG will also 
release an analysis toolkit based on the methodology OIG has 
developed in our extensive work on opioids to assist our public 
and private sector partners with analyzing their own 
prescription drug claims data to help combat the opioid crisis. 
This is an example of how we leverage our relationships and 
empower our partners to help us tackle this problem.
    OIG has also initiated work beyond Medicare. The work 
identifies opportunities to strengthen program integrity and 
protect at-risk beneficiaries across multiple HHS programs. For 
example, OIG audits and evaluations currently under way address 
a broad range of opioid-related funding and activity at HHS, 
including opioid prescribing in Medicaid, grants for 
prescription drug monitoring programs, FDA's opioid risk 
management program, and whether those in most need have access 
to medication-assisted treatment.
    In summary, OIG will continue to hold criminals 
accountable, and our work will result in impactful 
recommendations to improve program integrity, save taxpayer 
dollars, protect HHS beneficiaries from harm, and improve the 
quality and accessibility of treatment.
    Thank you, and I look forward to answering your questions.
    The Chairman. Thank you very much.
    Dr. Pattavina.

 STATEMENT OF CHARLES PATTAVINA, M.D., FACEP, MEDICAL DIRECTOR 
 AND CHIEF OF EMERGENCY MEDICINE, ST. JOSEPH HOSPITAL, BANGOR, 
                             MAINE

    Dr. Pattavina. Thank you, Chairman Collins and Ranking 
Member Casey, and good afternoon.
    The Senator gave a nice introduction earlier, but I should 
say I recently decided to take on a new role, which is Medical 
Director and Chief of Emergency Medicine at St. Joe's. I have 
been promoted to full-time patient care and work for the people 
I hired, and I am the immediate past president of the Maine 
Medical Association, and I served on the Board of the American 
College of Emergency Physicians from 1997 to 2003. I really 
appreciate the opportunity to speak to you today about the 
impact this terrible crisis is having on older Americans.
    Now, as you know, it claims the lives of almost 120 
Americans a day and about one a day in my State of Maine, and 
sadly, the number went up from 2016 to 2017 from 365 to 400, 
just as we thought we were turning the corner.
    And as the Chairman mentioned earlier, recent CDC data show 
an increase of about a third in opioid overdose emergency 
department visits by Americans over the age of 55 over a period 
that was barely more than a year, so we know this is a very 
serious problem.
    And also, I heard from the CDC this morning that the opioid 
epidemic is having a measurable negative impact on the life 
expectancy of Americans.
    While the effects of the opioid epidemic on seniors are 
similar to the effects on the population as a whole, it does 
present some unique challenges for older Americans. As we know, 
most people who are now addicted did start on prescription pain 
medications, although they were not necessarily prescribed for 
them. In many cases, they were obtained through illicit 
channels.
    We are seeing many cases in which people have become 
dependent on these medications and are tapered off them too 
quickly or even abruptly, and this creates problems.
    One of the problems we do have in treating people's pain, 
at least in conventional methods with medications, is that the 
choices are limited. There are the nonsteroidals, which the 
Chairman mentioned, that cannot be given to some people of any 
age, but particularly older people because of damaged kidney 
function or other illnesses that tend to be more common in 
older people. And there is Tylenol and pretty much everything 
else that is a prescription, but there are some things that are 
getting more use, such as lidocaine patches, and there are a 
number of other opportunities.
    But in terms of opioids, it is difficult in older people 
because of the existence of comorbidity. Certainly, the longer 
a person lives, the more likely they are to have more medical 
problems, and the effects of the drugs, especially in 
combination with others, can be magnified in this group, 
whether it is drowsiness, confusion, falls, as has been 
mentioned.
    I found the data brief very interesting and appalling, 
frankly. It is clear there is a very serious problem with 
outlier prescribers. A very small number of prescribers are 
writing for a very large number of opioids for a very small 
number of beneficiaries, and I appreciate the efforts you are 
taking to combat that problem.
    Regarding the prescription monitoring Web site, that has 
improved. Interestingly, even in spite of your efforts to 
require it, I believe I am still not seeing prescriptions from 
the Veterans Administration in the Maine PMP, and that is a 
problem.
    Patient perception of pain is a real challenge, 
particularly among those who have been on opioids for a long 
time. I am sure you hear from those people as well, and it is 
just an indication that great care and time must be taken to 
taper anyone's dose, so that people do not go outside the 
system seeking pain medication.
    And as was mentioned, there are a lot of great innovations 
and ideas out there that are coming forth from this terrible 
problem.
    We certainly do have a lot more resources than we had just 
a year ago, and the limits on prescribing Suboxone have been 
increased, as was mentioned, and I appreciate that. We can talk 
about that some more, but some action needs to be taken. We 
need more people willing to prescribe it, particularly in 
primary care.
    I am happy to say we do have some more resources in Bangor 
than we used to have. We have a social detox center funded by a 
state grant, and I will be happy to talk about anything else in 
the question session, but I appreciate the opportunity to be 
here today and help. Thanks.
    The Chairman. Thank you very much.
    Mr. Stauffer.

STATEMENT OF WILLIAM STAUFFER, EXECUTIVE DIRECTOR, PENNSYLVANIA 
                RECOVERY ORGANIZATIONS ALLIANCE

    Mr. Stauffer. First, I would like to thank Chairman Collins 
and Ranking Member Casey and other members of this Committee 
for hosting this important hearing and having the opportunity 
to testify on this critically important issue to the United 
States.
    My name is William Stauffer. I am a person in long-term 
recovery, continuous recovery, and for that, what that means to 
me is that I have not used drugs and alcohol for over 31 years. 
I think it is relevant to note to this Committee that I 
received treatment with public dollars, and that investment in 
my life made all the difference in the world. It has allowed me 
to be a responsible member in my own community.
    My recovery has allowed me to earn a college degree, to own 
a home, to be a good husband, to volunteer in my community, to 
pay taxes, to be a college professor, and become an advocate 
for the recovery community in the great State of Pennsylvania.
    The most remarkable thing about my kind of story is that it 
is quite common in the recovery community. We can do great 
things in recovery, no matter what age we start our journeys.
    I too will turn age 65 one day, and I hope that I and all 
those like me will have a full array of recovery support 
services and treatment options available to me and to other 
people in our community that may need them.
    Congress should work to ensure that this is the case, 
particularly as we have 10,000 baby boomers turning 65 every 
day in the United States.
    My written and oral testimony here today are as a result of 
my experience in recovery as well as my professional experience 
across three decades of service to our community.
    I run PRO-A, the statewide recovery organization. I have 
operated residential treatment facilities. I have operated 
outpatient counseling facilities, and I currently work as a 
professor of Social Work at Misericordia University, where I 
wrote a course on substance use and older adults.
    As was noted in the opening remarks, one in three Americans 
with Medicare coverage are prescribed opioid painkillers; 
however, while Medicare pays for opioid painkillers, Medicare 
does not pay for drug and alcohol treatment in most instances, 
nor does it pay for all the medications that are used to help 
people in the treatment and recovery process.
    Methadone specifically is a medication that is not covered 
by Medicare to treat opioid use conditions. It is important to 
note that the recovery community supports the use of medication 
as part of the treatment and recovery process. We strongly 
believe in multiple pathways to recovery. We understand that 
medications are important elements in the treatment and 
recovery process for adults seeking help with an opioid 
dependency, including for older adults. Recovery with 
medication is a reality for members of our community, as are 
other pathways.
    This Committee is showing true leaderships for focusing on 
the needs of older adults. We know full well that substance use 
conditions impact Americans of all age groups; however, the 
needs of older adults who have experienced a substance use 
condition get too often missed or ignored. The topic receives 
scant attention in the literature or training for medical 
professionals. There are few places to refer to who specialize 
in older adult care. Providers who want to meet these needs 
often cannot, as reimbursement rates are far too low.
    Older adults who have a problem face a triumvirate of 
stigma. Far too often family members, caregivers, and 
physicians fail to see, ignore, or underestimate the extent of 
the need for help.
    It is important to note that a long-term area of concern is 
the Institute of Mental Disorders exclusion, where costs get 
shifted to the Substance Use Prevention and Treatment block 
grant. Fixing this issue would help states have resources for 
older adults. The IMD exclusion has long been a barrier for 
treatment.
    We are deeply grateful to Senator Casey for his many years 
of support in efforts to get rid of the IMD exclusion. We are 
also grateful to Chairman Collins, who supports the elimination 
of the IMD exclusion. We urge you to remove drugs and alcohol 
from the IMD exclusion as the Road to Recovery Act would do. 
This will allow older adults' service to be paid for out of the 
Substance Use Prevention and Treatment block grant instead of 
diverting resources from the IMD.
    We applaud Senator Casey for his bill that would have 
Medicare pay for methadone. We would take additional steps to 
ensure that people are treated properly and that when an older 
adult has a substance use disorder that their needs are met in 
a full continuum of services.
    We applaud efforts being made in Congress to expand 
medication-assisted treatment to Americans 65 and older, and we 
know that this is a fast-growing area of need.
    We must expand education to physicians and other 
practitioners so that the unique challenges of older adults are 
met, and we must provide sufficient resources to make sure that 
services are available.
    I want to thank all of you for this opportunity to shed 
light on this important issue. I think this is just a start. I 
think we have to have more hearings to make sure that needs are 
met for older adult Americans. Thank you.
    The Chairman. Thank you very much for your testimony, and 
congratulations. That is an impressive story.
    Mr. Stauffer. You mentioned YPR. I currently refer to 
myself as a formerly young person still in recovery.
    Thank you.
    The Chairman. Thank you.
    Professor Terry, it looks like you are stuck with me as the 
introducer. I will introduce you as a professor of law and 
executive director of The William S. and Christine S. Hall 
Center for Law and Health at Indiana University. Professor 
Terry is the author of a book or a co-author of a report titled 
``Legal and Policy Best Practices in Response to the Opioid 
Epidemic,'' and would not you know?
    [Laughter.]
    The Chairman. I just introduced your witness, but you are 
welcome to add something to it since----
    Senator Donnelly. I will add an extra word, which is thank 
you, Chairman Collins, for also introducing----
    The Chairman. There you go.
    Senator Donnelly [continuing]. Nic Terry from Indiana 
University.
    Mr. Terry is a professor of law and executive director of 
the Hall Center for Law and Health and IU Law School. He 
recently helped lead a team of researchers in creating a report 
titled ``Legal and Policy Best Practices in Response to the 
Substance Abuse Crisis.'' This research was conducted as part 
of IU's $50 million Grand Challenge Initiative to address the 
opioid epidemic in Indiana.
    This has been a heartbreaking challenge. We have lost so 
many young people who could have been the next nurse, the next 
teacher, the next policeman, and I know we are all in this 
together to beat this.
    And, Mr. Terry, we are thrilled that you are here. Thank 
you.

 STATEMENT OF NICOLAS P. TERRY, PROFESSOR OF LAW AND EXECUTIVE 
DIRECTOR OF THE WILLIAM S. AND CHRISTINE S. HALL CENTER FOR LAW 
                 AND HEALTH, INDIANA UNIVERSITY

    Mr. Terry. Thank you for both introductions.
    Senator Donnelly. Hers was probably better.
    [Laughter.]
    Mr. Terry. Thank you, Chairman Collins, Ranking Member 
Casey, and Committee members for this opportunity.
    In our research, we noted positive steps taken in our state 
and elsewhere, such as various supply side approaches to 
reducing the number of opioids in circulation. While perfection 
can be the enemy of the good, sometimes good is not good 
enough.
    We concluded that we could do much more, specifically 
prioritize harm reduction such as by supporting the work of 
syringe exchange programs, creating more safe spaces, and 
reducing stigma; by removing legal impediments that hold up 
effective responses, such as by better coordinating federal 
privacy laws; and make careful and sustaining investments in 
health care services to provide more and improved evidence-
based treatment.
    There are several complicating factors involving opioid use 
in the elderly. Because of chronic pain, the near-elderly and 
elderly likely will be longer-term users of opioids. Medication 
sensitivity increases with age. Polypharmacy heightens risk 
associated with SUD. Drug hoarding and drug sharing are common. 
Comorbidities increase the risk of missing an OUD diagnosis.
    Indeed, opioid use has been associated with fall-related 
injuries and death among older adults. Risks of injury and 
death are substantially higher among older adults with opioid 
use disorder, and rural older adults are dying from the opioid 
epidemic at a slightly higher rate than older adults generally.
    Many of the aspects of this crisis apply equally to seniors 
and juniors, but some specific complicating considerations also 
come into play.
    First, care coordination challenges. Persons suffering from 
SUD and frequent comorbidities such as mental health diseases 
are particularly vulnerable populations that in practice 
require additional and particularly robust levels of care 
coordination. These unmet needs likely are exacerbated when we 
combine additional comorbidities associated with the near-
elderly and elderly.
    Hospital readmissions among the elderly are a useful proxy, 
with a higher rate of readmission among seniors with multiple 
symptoms, such as cognitive impairment and polypharmacy. 
Indeed, the readmissions penalty program is an attempt to make 
hospitals commit to wraparound services, including home visits 
to assist vulnerable populations.
    The best-known case management, care coordination, and 
wraparound services model is that adopted by the Ryan White 
HIV/AIDS Program. By filling gaps between existing programs and 
services and because it is a payer of last resort, the program 
has been extremely successful in reducing AIDS-related 
mortality and morbidity. It is a thoughtful model to follow 
anytime we examine health care services for vulnerable 
populations.
    Second, access. Access issues will remain with long waiting 
lists, limited treatment availability in some rural areas, and 
quality issues caused, for example, by facilities being detox-
only or not offering a full range of evidence-based medication-
assisted treatments.
    Approximately 23 percent of the Medicaid population are 
over 45 years of age. We know that CMS is highly supportive of 
state flexibility in Medicaid services, and states are 
leveraging Section 1115 waiver authority to test innovations. 
However, some recently approved waivers, such as paperwork 
requirements for establishing eligibility and premium payments, 
may disproportionately affect persons with SUD and 
comorbidities.
    More positively, Section 1115 waivers may be available to 
implement innovations in behavioral health such as suspending 
the IMD exclusion, reimbursing care coordination, or paying for 
services that address health-related social needs such as 
supportive housing, transportation, and food.
    Finally, undertreatment. One of the frequent calls to 
action during the opioid crisis is to reduce overprescribing 
and overtreatment. However, as overtreatment is brought under 
control, the pendulum may swing too far in the other direction.
    According to SAMHSA, nearly half of older Americans suffer 
from a chronic pain disorder, and the instance of chronic pain 
increases with age. Even today, pain among older adults is 
largely undertreated.
    Denying prescription opioids to a cohort that suffers from 
chronic pain and in the case of the elderly or near-elderly has 
been treated for a decade or more with opioids could have 
serious consequences, undertreatment and the possibility of 
that cohort turning to illegal drugs.
    In preparing these remarks, we found gaps in the data and 
relatively little evidence-based research discussing opioid 
misuse among elderly cohorts, suggesting that additional 
research is warranted.
    Once again, I express my thanks to the Committee for this 
opportunity. Going forward, I and other members of the Indiana 
University Grand Challenge team will be at your disposal.
    The Chairman. Thank you very much, Mr. Terry. I think you 
have raised an awfully good point about the pendulum swinging 
back and forth.
    I remember 15 years ago being at a hearing when we were 
talking about the undertreatment of pain, and now we are in a 
situation where we have gone the opposite way. And we have to 
somehow figure this out.
    Mr. Cantrell, in your testimony, you referenced doctor 
shopping as being a problem, and I was surprised to hear that 
because most states have adopted prescription drug monitoring 
data bases. And I am wondering if this is an issue where 
prescribers are not checking the data base or whether the data 
base does not have current data or whether fraud is involved. 
Tell us a little bit more about how it is possible for doctor 
shopping still to exist.
    Mr. Cantrell. Well, thankfully, it was the smallest number 
of beneficiaries, around 20,000 who were doctor shopping seeing 
four or more pharmacists or four or more doctors.
    I think there are a number of reasons. This is 2016 data. 
We continue to see improvement in prescription drug monitoring 
programs, but we know that they are not deployed consistently 
across the country, that some require checking in more real 
time and some do not. Some provide greater access to other 
entities, to review that, to monitor for doctor shopping or 
overprescribing. So I think it is maybe a product of fraud 
potentially, and also a product of inconsistent utilization of 
PDMP data.
    The Chairman. Thank you.
    Dr. Pattavina, in your testimony, you mentioned the 
challenges around patient perception of pain--and we do all 
have different thresholds in experiencing pain--and the danger 
that patients or their family members might seek out street 
drugs if they feel that their pain is not being adequately 
addressed, and obviously, that puts an individual at much 
greater risk for an overdose.
    Can you describe or are you aware of any specific 
situations where that has occurred?
    Dr. Pattavina. Yes, I can. Thank you for that question, 
Senator.
    Yes. As you indicated, in my experience, it is clear that 
some people suffer more from their suffering or from their pain 
than others do, and when working with these people, it is 
important to have a compassionate and kind discussion with them 
because that is really the cornerstone of any interaction we 
have, including helping them understand, but that for the most 
part, these medications, the opioid medications are for short-
term pain relief. And one can go over some of the initiatives 
and innovations that are out there.
    In terms of a specific incident, I was informed of a 
specific incident in which an older woman was in a nursing 
home, and it was known to the staff that her family felt her 
pain was being undertreated. And the nurses actually found the 
patient to have the signs and symptoms of an overdose, and 
treated her with Narcan. She started to breathe again, and she 
was taken to the hospital. And it is their strong suspicion 
that she was given some kind of street drug by the family.
    The Chairman. What do you believe is the most effective way 
for us to educate patients and their families who are 
distrustful of plans that involve tapering the use of opioids?
    Dr. Pattavina. That is a challenge because so often they 
are afraid.
    The Chairman. Exactly. They are going to be fearful that 
the pain is going to come back, I would think.
    Dr. Pattavina. Right. And what has really happened, of 
course, is they have developed a tolerance to the medication. 
So they are really not any better off now than they were before 
they were on the medication, but that explanation only goes so 
far.
    I have long felt that we need to do a better job of 
highlighting the success stories because there are people who 
have come off them who feel a lot better, but somehow we need 
to connect those people with each other, perhaps just doing a 
better job of publicizing it, because people can have a better 
life off these medications.
    The Chairman. Thank you.
    Senator Casey.
    Senator Casey. Thank you, Madam Chair.
    I want to start with Mr. Stauffer, not just because he is 
from Pennsylvania, but that helps.
    We know that experts, including the President's Opioid 
Commission, note that ``complex'' policies create barriers for 
seniors and people with disabilities who are in fact seeking 
treatment. This includes coverage rules under Medicare that 
limit patient access to outpatient treatment programs.
    In your testimony, you indicate that medications, including 
methadone, are important elements in the treatment and recovery 
process for adults seeking help with an opioid dependency, 
including older adults. Could you explain why expanding 
Medicare coverage to include methadone would make a difference 
to the clients you serve and older adults across the country?
    Mr. Stauffer. Yes. Thank you for the question.
    What we are seeing is we also have individuals who are 
currently receiving methadone who when they turn 65, it becomes 
a challenge to pay for it. That is one group of individuals who 
this would be applicable to.
    We need to think about having all options available to 
people seeking help with a substance use condition, so having 
every tool in the toolbox available, and we are in the middle 
of--I would call it an addiction epidemic because we narrow it 
down to opioids. Older adults, really we also have to be 
concerned about alcohol. So we want to make sure that we have 
all the tools available for clinicians to make good decisions 
about the care that they are providing.
    I would want to note that we want to have great care in how 
methadone is used for older adults for a lot of the reasons 
that were identified in this gentleman's testimony about the 
effects of medications on older adults. We want to make sure 
that their tolerance for it and their ability to eliminate it 
from their bodies, because that changes with age. We want to 
think about things like that as well as multiple drug 
interactions. Those are things that are important.
    But I think having all things available in a continuum of 
care is critically important as we move forward. I would 
suggest that we are asking the wrong question when we come to 
serving people with substance use disorders. We know that in 
America that people who achieve five years of recovery have 
about an 85 percent chance of staying in recovery for the rest 
of their lives. We should be formulating our systems of care 
around making sure that individuals get those services so that 
they can get the five years. Things like treatment, peer 
support services, and things like that would be very important 
for that, those needs.
    Thank you.
    Senator Casey. I know that we hear a lot about naloxone all 
across the country, sometimes known as Narcan, and the life-
saving potential of it, and we should applaud those efforts by 
states, including states like Pennsylvania that ensure that 
people can have access to this kind of life-saving treatment 
without a prescription.
    But we should do more because naloxone should be in the 
hands of every person who might need it. For instance, a high 
deductible or a copayment should not stand in someone's way.
    So I wanted to start with two questions, one for Dr. 
Pattavina. What are the common barriers that prevent people 
from receiving naloxone, and what more should Congress do to be 
breaking down those barriers?
    Dr. Pattavina. Well, Senator, thanks for that question.
    One huge barrier is that it is often available only by 
prescription, and a lot of us think that it really ought to 
just be available over the counter. That would remove a number 
of complications and difficulties in getting it.
    It is about as harmless as a medication could be, really. 
There is not much you can do with it. So we think over the 
counter would be one.
    The other thing is the cost. Insurance coverage is a little 
variable, but it can be actually very expensive, I think even 
up to $200, if someone without insurance has to actually buy 
it, so the drug price is also an issue.
    Senator Casey. And I only have about 30 seconds, but, Mr. 
Stauffer, your experience in our home state?
    Mr. Stauffer. Yes. I would characterize Narcan as the 
equivalent of giving somebody who is having a heart problem, 
just reversing and putting their rhythm back in place. It is 
not like a treatment. It is like saving the life immediately.
    You know, I have had the opportunity to meet a librarian 
from Philadelphia that has saved a half dozen lives.
    Senator Casey. Yep.
    Mr. Stauffer. I am hearing of--there is a gallery, an art 
gallery, where the artists have saved a number of lives. I 
carry it. I could not agree with you more that we need to 
reduce copays and expense of this. It should be available to 
everyone. We should make it available to anybody who goes to 
treatment for any substance use condition, their families. We 
should make it as available to the general public as is 
possible, so that everyone has an opportunity to reverse an 
overdose.
    Thank you.
    Senator Casey. Thanks very much.
    Thank you, Madam Chair.
    The Chairman. Thank you.
    Senator Cortez Masto.
    Senator Cortez Masto. Thank you. And let me just say thank 
you again for an incredibly compelling and necessary 
conversation today. I do not think opioid abuse is immune in 
any community. Everybody is affected by it, including in the 
State of Nevada.
    A couple of things that--and we have been working on this 
for a number of years because we have a similar statistic, 
unfortunately, in Clark County where 70 percent of the 
population lives. The number one cause of death is overdose, 
the statistics that we got from our coroner as well, and this 
was so enlightening a couple of years ago when we saw the 
trajectory and what was happening here.
    So let me pose this because what I have found after working 
in substance abuse treatment for a number of years are three 
pillars: education awareness, intervention treatment, 
enforcement. There has to be a bridge between all of those, and 
they have to work together.
    The challenge that I have found literally is on this 
treatment side and enough dollars for treatment, but also the 
type of treatment. Unfortunately, in the work that I have done 
in the past, what I have seen is for anybody in the State of 
Nevada, at that time to get any type of treatment, had to 
commit a crime because there were not enough treatment 
providers, and you could not voluntarily go and afford it. That 
is horrific to me, and I think that is still happening. So it 
is something we have to address and tear down those barriers so 
people have access voluntarily to get the treatment they need 
without having to commit some sort of crime.
    With that said, I am curious, and I am going to open it up, 
and maybe, Mr. Terry, start with you. You talked about some of 
those barriers. Are there additional barriers that we should be 
looking at here at the federal level to tear down to make sure 
people have access to treatment?
    And then let me also say the treatment is key. Whether it 
is evidence-based--or you are the providers. You know better, 
Dr. Pattavina and Mr. Stauffer, that at the same time, we know 
there are fraudulent programs out there. And that is why my 
colleague and I--Senator Moore Capito--introduced legislation 
to be able to go after those fraudulent programs that are out 
there that claim to provide some sort of treatment for opioid 
abuse.
    But can you talk about how we tear down the barriers, but 
how do we ensure as we tear down those barriers that our loved 
ones are getting to the necessary treatment they need and the 
type of treatment, and how do we steer them toward it? How do 
we know? How does a loved one know? How does an individual know 
the right treatment that is available for them?
    And maybe I will just open it up and start with you, Mr. 
Terry.
    Mr. Terry. Well, thank you, Senator.
    I think you can hit that just at a very high level or a 
very low practical level. Let us start with the second of 
those.
    You have to see this as a care continuum, and we have to 
take a broader view of what the care continuum is here. That 
when someone goes down and is rescued by an naloxone shot from 
EMS or law enforcement, that is not the end of it.
    Senator Cortez Masto. Right.
    Mr. Terry. It needs to be the beginning of getting that 
person to treatment.
    When someone walks into a syringe exchange and they start 
trusting the people there, then that has to be the beginning of 
getting them moving toward treatment.
    When people do not trust law enforcement or they are in 
areas where there are not good facilities, we need to think 
about more and better safe places. There are some wonderful 
examples, almost romantic examples from around the country of 
firehouses opening up and becoming safe spaces, again, with 
movement on to treatment.
    When people go into an emergency room, there should be a 
way from there for a referral for peer help and move them into 
treatment.
    To go back to my 5,000-feet observation, this is not what 
you want to hear, but to a large extent, the opioid prescribing 
crisis is a function of problems in our health care system. We 
have a dramatically fragmented, uncoordinated, somewhat 
haphazard system. It is staffed by persons doing incredible 
work, but the system itself is very, very difficult. I am sure 
you have been told a hundred times that the opioid crisis is a 
wicked problem. One of the definitions of a wicked problem is 
it is part of another problem, and so anything we can do to fix 
our health care system would be really useful.
    I do think that something like the Ryan White program is 
the gold standard, but I also think we have wonderful health 
department and Medicaid directors, including those in Indiana, 
who have got great imaginations and if given the right kind of 
funding and discretion can find the levers to pull here.
    We have got managed care entities who are working with 
Medicare and Medicaid that know how to create wraparound 
services and provide metrics and be accountable for them, and 
we have states that are using Section 1115 behavioral health 
waivers to design some really interesting, innovative, and 
quite different types of care coordination case management 
models. And we need to maybe ask someone if we could take the 
budget-neutral piece out of those Section 1115 waivers and see 
what we can do to really let those people fly and innovate.
    Senator Cortez Masto. Thank you.
    And I know my time is up. May I follow up, Madam Chair?
    The Chairman. Yes.
    Senator Cortez Masto. So let us talk about this wraparound 
services because I absolutely agree. How do we ensure we are 
funding those services and people are getting to the type of 
treatment they need? Not everybody needs the same type of 
treatment, and how do we as individuals who are ensuring--we 
are putting funding out there to focus on treatment. How do we 
know the right kind of treatment is being created in our 
communities?
    And let me open that up. I do not know, Mr. Stauffer or Dr. 
Pattavina, if you have any ideas.
    Mr. Stauffer. Yes. First, I want to comment that this is 
our leading public health crisis in the United States, not just 
the opioid epidemic. It sits inside of a larger issue.
    The White House has noted that it is costing us 2.8 percent 
of our GDP, in addition to driving down life expectancy in the 
United States.
    I think we have to stop focusing on episodic care. We need 
to focus on long-term needs and ensuring that our community 
gets help.
    When somebody gets a cancer diagnosis in the United States, 
there is a focus on getting that person to be in remission for 
5 years. Everybody knows that that is what is needed. Reframing 
our system to ensure that that is the case, so if one 
particular treatment does not work, that you try another one.
    The needs of older adults, as was mentioned by the 
testimony of my colleague here, they are really complex. So we 
need to make sure that there is enough funding there for 
service providers to properly serve the person, or else we will 
end up with haphazard care.
    And I applaud the Office of Inspector General's efforts to 
hold people accountable and programs accountable who are doing 
bad things. That is really important to the recovery community, 
and those steps are what we need to do to move toward making 
sure that there is effective care in the United States.
    Senator Cortez Masto. Thank you.
    Dr. Pattavina. Thank you, Senator.
    I have a few thoughts. I guess the easy answer would be 
there just are not enough of so many types of services, maybe 
particularly residential or recovery services, but I know you 
have all been part of appropriating a lot of money toward these 
things. And it can be frustrating to you that it has not been 
spent yet, so I know that is an issue.
    One of the thoughts I have had is Suboxone, and I refer to 
it by its brand name because it is a combination product and it 
otherwise would have a very long name.
    It really belongs in sort of the medical home of primary 
care, as you were alluding to earlier or outright said. It is a 
person's medical need, and in many cases, these people are 
already patients of a primary care practice, and they either 
have not divulged it or the practitioner is unaware of it, has 
not figured it out, or in many cases practices actually 
discourage people from becoming Suboxone providers and getting 
the X waiver. So that is a problem. I could go into some 
reasons I think that is a problem.
    But I also appreciate the efforts--and I apologize if 
others of you are also sponsors of the effort to codify the 275 
in the law, but that is definitely a step in the right 
direction.
    I would suggest we think about going even further, though, 
and removing all the special requirements around prescribing 
Suboxone, since it is about as harmless as naloxone. And we 
certainly in medicine deal with medications that are much more 
dangerous than that and particularly in emergency medicine.
    You may not have seen it, but there was an article in last 
month's Atlantic about the French experience, and we are not 
France, but we can always learn from other people. And in 1995, 
they removed all of the requirements, the special requirements 
for prescribing Suboxone. The number of people on it went up 10 
times, and overdose deaths went down 79 percent in a period of 
time. Of course, that was an Atlantic article. You people have 
access to good facts, but I strongly suggest we look into that.
    Senator Cortez Masto. Thank you.
    Thank you, Madam Chair.
    The Chairman. Thank you, Senator.
    I am going to follow up on the point that you just raised 
about Suboxone because I am a cosponsor of the legislation that 
codified the expansion, but I am fascinated, Dr. Pattavina, 
about what you just said because I have noticed in Maine that 
there is still a hesitation by a lot of primary care physicians 
to take the training that would allow them to administer 
Suboxone.
    And particularly in the more rural areas of the state, 
where we do not have treatment centers, we really need for 
primary care physicians--and I would argue physician assistants 
and advanced practice nurses--to be willing to do that.
    So what do you see, looking at a rural state like ours, as 
the primary barrier because I expected a big increase once we 
got the regulatory relief, and we have seen an increase, but it 
has not been near what I would have hoped.
    Dr. Pattavina. Yes. It is a little perplexing. In fact, in 
Machias and Calais, the emergency departments there are 
attempting to start programs where they would start people on 
the medication because the emergency clinicians have the waiver 
or are getting it, yet there is no one in the community to hand 
them off to. And that is a real barrier.
    There is the stigma, unfortunately, and I suspect there is 
perhaps even a fear that maybe a practice that was doing this 
might attract more of these people who know. Although, most of 
them are like you and me. There is fear that they might be 
disruptive or things like that, and I know practices do in fact 
screen patients prior to accepting them as part of the practice 
by looking at the PMP and their medication lists and things.
    But I think it really needs to be a change in consciousness 
that filters to the people out there in practice that this is a 
person's medical need, and you may already have these people in 
your practice. And it would not be a bad thing to have more of 
them.
    But the training itself is a little bit of a barrier for a 
physician. It is eight hours, which is eight fewer hours with 
your family or at work, but that is not huge. But a lot of it 
is just not knowing. So somehow we need to do a better job of 
getting that out there.
    The Chairman. That is very helpful because one of my 
theories was that perhaps if you are a primary care physician 
in a smaller community that you are worried that your whole 
practice is going to end up being treating those with substance 
abuse problems and opioids in particular, and you want more of 
a variety in your practice. And there is such a need, 
unfortunately, in our state, and it seems like the rural areas 
are even more affected.
    And I see Professor Terry nodding that that is the case. I 
know that has been the case in Indiana, and so that we really 
need those primary care physicians.
    Did you want to add something to that, Mr. Terry?
    Mr. Terry. No. I was nodding that was the correct thing. 
The treatment centers in rural areas are very low percentage.
    We have a shortage of psychiatrists in the country. The 
number of psychiatrists are not growing as fast as other 
medical specialties or primary care physicians. Psychiatrists 
tend to be older. They tend to live in urban areas.
    And I think we have to recognize that while we have some 
drugs that are miraculous, like naloxone, which brings people 
almost back from death, treatment is not like that, and we 
salute those who take the long path and are successful. But for 
most people, even really good medication-assisted treatment is 
not always going to be successful. It is time-intensive for 
providers. People relapse. They try and go back into work. They 
get drug-tested. They then have work problems.
    So taking a step back and really trying to assemble 
multiple strategies for dealing with these issues is so 
important.
    The Chairman. Mr. Stauffer?
    Mr. Stauffer. And I would just want to add that we do not 
have a panacea, and so buprenorphine can be life-saving. It is 
best from the literature, I have seen. Combined with therapy 
and peer-support services. So we want to have great caution to 
make sure that we are doing more than just medication, that we 
are combining it and coordinating. So what can be done at the 
federal level is really thinking about how do we ensure that 
those other services occur in combination with the medication 
for its most effective result.
    The Chairman. Dr. Pattavina?
    Dr. Pattavina. Yes. I would like to agree with that. It is 
medication-assisted therapy, and I think that could be a 
roadblock as well, having a primary care practice need to 
coordinate the medication with counseling. And to be fair, it 
is an added expense as well. They have to do pill counts and 
periodic testing to make sure the patient is taking the 
medication. So I know that is an issue as well.
    The Chairman. Thank you.
    Mr. Cantrell.
    Mr. Cantrell. Thank you.
    I just wanted to highlight some work that we have under way 
that may help shed light on this issue of access to 
buprenorphine.
    We are looking at a number of certified prescribers, 
certified by SAMHSA to prescribe buprenorphine across the 
country, looking at geographic distribution of those that are 
certified, and also mapping that against those counties where 
there, based on data from the CDC and SAMHSA, appear to be the 
greatest need because of overdose rates or prescribing 
practices. And that work is under way. We want to follow up 
that work with surveys to certified prescribers to delve into 
some of these issues, so a preview of some work that is to 
come.
    The Chairman. We will be having you back. I have no doubt.
    Mr. Cantrell. Great.
    The Chairman. Dr. Pattavina.
    Dr. Pattavina. Just one more piece of information you might 
be interested in, if you do not have it, is in Maine, there are 
600 people certified to prescribe Suboxone, and they can choose 
whether or not to be listed on the DEA Web site, I think it is. 
Only 260 of them are listed there, and only five are 
prescribing at the limit. And it gets even worse: two of them 
are at the 30 limit, and the other three are at the 100 limit.
    The Chairman. That is fascinating and tells you a lot about 
the concerns and the stigma also, I think.
    Senator Casey.
    Senator Casey. Mr. Cantrell, I wanted to ask you a question 
about some of our responses in the Medicare context. The 
office, your office, shows that one in three people with 
Medicare Part D are prescribed opioids. The fact that that is 
the case makes clear that seniors are among those most at risk 
here.
    This fact has not been the real focus, frankly, of much 
policy debate or all that much press attention or even academic 
study, which Mr. Stauffer pointed out in his testimony. Older 
adults are among the most unseen in this whole crisis.
    I guess two parts. What additional analyses is OIG planning 
to do to shed light on these issues? Or I guess another way of 
asking that, what additional investigations, if any?
    Mr. Cantrell. The first thing we are doing is we are 
releasing an update, as I mentioned earlier, regarding the data 
we put forth regarding 2016 prescribing. We will be looking to 
see where those trends are headed, how many patients are 
receiving those extremely high dosages based on 2017 claims 
data.
    We are also interested in looking at Medicaid data. We do 
not have great access to national Medicaid data, so we cannot 
replicate the analysis that we have done in Medicare across all 
50 states, but we will be looking one state at a time to 
conduct the same analysis to see what is happening in the 
Medicaid programs. So I think those are important areas that we 
will continue to monitor.
    We are also working very closely with CMS as well as our 
partners. When we identify these beneficiaries, we share them 
back to CMS so that they can monitor these patients as well and 
utilize whatever tools they have available to them to help care 
for these individuals.
    We also shared the outlier prescribers, and I am a member 
of the Health Care Fraud Prevention Partnership, which is 
public and private payers. And we have data use agreements and 
data sharing agreements through that partnership, so we can 
share data like that, and we have, through the partnership, so 
that all these private plans can look to see if they are 
impacted by these outlier prescribers as well.
    So we know it is not something we can do alone. So we are 
ensuring that we make the data that we have available to us as 
accessible as we can while, of course, honoring security and 
privacy requirements, but also teaching others how do to the 
same analysis so that everyone can perform at least the same 
types of analysis that we are.
    Senator Casey. Thanks very much.
    The Chairman. Thank you.
    Senator Cortez Masto, I almost called you ``Doctor.'' I do 
not know why.
    Senator Cortez Masto. That is OK. Thank you.
    Let me follow up, Mr. Cantrell, because this was something 
I was thinking about, and you actually touched on it. I think 
there is a connection here.
    So in many of the Attorneys General offices across the 
country, including in Nevada, there is a Medicaid fraud unit, 
and the focus--most people do not realize. That is why I know 
senior care is a focus of this Medicaid fraud, the level of 
care that is provided to our seniors and the fraud that goes 
along with it.
    I think there are additional resources to address the law 
enforcement piece through our state law enforcement and not 
just rely on federal law enforcement, where there is this fraud 
associated with opioid abuse, and the connection to CMS 
because, as we know, CMS is the overseer for those Medicaid 
fraud units. And I think there is an opportunity. If there is a 
way that I can help work or we can help work and kind of tear 
down those barriers or connect those dots, I think that would 
be helpful as well.
    Mr. Cantrell. We have an outstanding relationship with the 
Medicaid fraud control units. They are our partners. We work 
together in the field, and we learn from one another. So there 
is no concern regarding the relationship with our Medicaid 
fraud control unit partners, and we do work closely with them 
in these districts where opioids are a problem, to look across 
both the Medicaid and the Medicare data.
    In fact, OIG oversees the grants for funding the Medicaid 
fraud control units, and so we have a very close and tight 
relationship with those units. And we work very well together.
    We could use better national Medicaid claims data. That is 
something that CMS is working toward. We are not there yet, so 
we still cannot leverage that data the same way we can the 
Medicare data.
    Senator Cortez Masto. That is good to hear, and however we 
can be helpful, please let me know or let us know.
    Thank you.
    Mr. Cantrell. Thank you.
    The Chairman. Thank you very much.
    Well, I want to thank Senators for getting here and being 
very efficient with their questions, since the votes are going 
to start in 3 minutes.
    I want to thank all of our witnesses.
    [Voting Notice Clock Buzzes.]
    There it is.
    Mr. Stauffer, you in your statement wrote something that 
really summarizes why we are having this hearing today, and you 
said that substance abuse conditions in older adults receive 
scant attention in the literature and that there is almost no 
training for medical professionals to identify and refer 
persons to care for a substance use condition to get the help 
that they need. And I would add to that that there is a lack of 
awareness that substance abuse and opioid addiction is not just 
a problem affecting young people, and the spike in emergency 
room admissions for those age 55, I think it was, an older by a 
third demonstrates that.
    So I hope that our hearing today will raise greater 
awareness of the challenges that are facing older Americans, 
particularly those who do have chronic pain and may have been 
on a large dosage of opioids for many, many years, and theirs 
is a difficult issue for health care providers and for the 
patient and the patient's family.
    We also need to--and I believe have done today--highlight 
opportunities to improve care for all those who are struggling 
with addiction, and that does mean better care coordination. I 
thought Dr. Pattavina's point that it is not just a matter of 
giving the medication-assisted therapy. It is called 
``medication-assisted therapy'' for a reason, and if it is not 
surrounded with those wraparound services, it is less likely to 
be effective.
    And, of course, GAO's contributions and the OIG's 
contributions are always extremely valuable. The Inspector 
General's report has some really startling statistics.
    And, as usual, Senator Cortez Masto anticipated my question 
because I was wondering what happens to those providers who we 
know are outliers. Are they given guidance and, thus, monitored 
by their peers? Are they turned over to the Medicare task 
force? Are they turned over to state medical boards? What 
happens? And that is an area that we will be looking further 
into as well.
    But I want to thank all of you for sharing your insights 
with us as we grapple with this problem.
    As Dr. Pattavina mentioned, I was so discouraged when the 
numbers of those who overdosed in the State of Maine last year 
actually increased by 11 percent, despite far greater 
awareness, despite new programs, new approaches, and yet we did 
not see any improvement. We went backward.
    So, clearly, more needs to be done, and I think more help 
is on the way. But I really want to make sure that this $6 
billion, which is a lot of money, gets down to the local level, 
and that is something I think we are going to have to work on.
    Senator Casey, I would invite you for any closing thoughts.
    Senator Casey. Thank you, Madam Chairman, and thanks for 
holding this hearing. It is critically important.
    I also want to thank all our witnesses for your presence 
here today, your testimony.
    Bill, thank you for making the trip from Pennsylvania and 
for your service to the people of Pennsylvania and sharing it 
from your own personal perspective as well as all the 
experience you have in helping us better understand this 
challenge.
    As we heard today, the opioid crisis is affecting big 
cities and suburban communities, small towns, and rural areas. 
It is affecting every generation. There is no bounds of age. We 
all have a sacred responsibility to care for pregnant mothers 
and their newborn infants struggling to overcome opioid misuse. 
We have a responsibility to the unsung heroes of this crisis--
grandparents who are now raising their grandchildren.
    Today, we learned that one too many senior is struggling to 
access proven treatments for opioid misuse. The Federal 
Government must use every tool at its disposal to blunt the 
harms of this crisis.
    So we look forward to continuing to work with folks in this 
room and folks all across the country and here in the Senate on 
a bipartisan basis.
    Last, I will just make one point at the end. I was going to 
get to one of these in my questions on Medicaid. Medicaid 
covers opioid treatment for 4 in 10 Americans. In fact, in 
2014, Medicaid was the second largest payer, second only to 
state and local governments for opioid treatment. So when we 
are debating how to deal with the opioid crisis, we have got to 
protect Medicaid.
    Madam Chair, thank you very much.
    The Chairman. Thank you.
    Senator Cortez Masto, do you have any final thoughts?
    Senator Cortez Masto. No, Madam Chair. Thank you.
    The Chairman. Thank you.
    I want to thank our staff also for their hard work on this 
hearing, and Committee members will have until Friday, June 
8th, to submit any questions for the record. So it is possible 
some additional questions will be coming your way.
    Again, thank you for your participation. This hearing is 
now adjourned.
    [Whereupon, at 3:19 p.m., the Committee was adjourned.]

 
      
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                                APPENDIX

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                      Prepared Witness Statements

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