[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
--------------------------------------------------------------------------------------
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.]
=======================================================================
APPENDIX
=======================================================================
Prepared Witness Statements
=======================================================================
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
[all]