[Congressional Record Volume 162, Number 73 (Tuesday, May 10, 2016)]
[House]
[Pages H2166-H2172]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]
PROMOTING RESPONSIBLE OPIOID MANAGEMENT AND INCORPORATING SCIENTIFIC
EXPERTISE ACT
Mr. MILLER of Florida. Mr. Speaker, I move to suspend the rules and
pass the bill (H.R. 4063) to improve the use by the Secretary of
Veterans Affairs of opioids in treating veterans, to improve patient
advocacy by the Secretary, and to expand the availability of
complementary and integrative health, and for other purposes, as
amended.
The Clerk read the title of the bill.
The text of the bill is as follows:
H.R. 4063
Be it enacted by the Senate and House of Representatives of
the United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Promoting Responsible Opioid
Management and Incorporating Scientific Expertise Act'' or
the ``Jason Simcakoski PROMISE Act''.
SEC. 2. IMPROVEMENT OF OPIOID SAFETY MEASURES BY DEPARTMENT
OF VETERANS AFFAIRS.
(a) Expansion of Opioid Safety Initiative.--
(1) Inclusion of all medical facilities.--Not later than
180 days after the date of the enactment of this Act, the
Secretary of Veterans Affairs shall expand the Opioid Safety
Initiative of the Department of Veterans Affairs to include
all medical facilities of the Department.
(2) Guidance.--The Secretary shall establish guidance that
each health care provider of the Department of Veterans
Affairs, before initiating opioid therapy to treat a patient
as part of the comprehensive assessment conducted by the
health care provider, use the Opioid Therapy Risk Report tool
of the Department of Veterans Affairs (or any subsequent
tool), which shall include information from the prescription
drug monitoring program of each participating State as
applicable, that includes the most recent information to date
relating to the patient that accessed such program to assess
the risk for adverse outcomes of opioid therapy for the
patient, including the concurrent use of controlled
substances such as benzodiazepines, as part of the
comprehensive assessment conducted by the health care
provider.
(3) Enhanced standards.--The Secretary shall establish
enhanced standards with respect to the use of routine and
random urine drug tests for all patients before and during
opioid therapy to help prevent substance abuse, dependence,
and diversion, including--
(A) that such tests occur not less frequently than once
each year; and
(B) that health care providers appropriately order,
interpret and respond to the results from such tests to
tailor pain therapy, safeguards, and risk management
strategies to each patient.
(b) Pain Management Education and Training.--
(1) In general.--In carrying out the Opioid Safety
Initiative of the Department, the Secretary shall require all
employees of the Department responsible for prescribing
opioids to receive education and training described in
paragraph (2).
(2) Education and training.--Education and training
described in this paragraph is education and training on pain
management and safe opioid prescribing practices for purposes
of safely and effectively managing patients with chronic
pain, including education and training on the following:
(A) The implementation of and full compliance with the VA/
DOD Clinical Practice Guideline for Management of Opioid
Therapy for Chronic Pain, including any update to such
guideline.
(B) The use of evidence-based pain management therapies,
including cognitive-behavioral therapy, non-opioid
alternatives, and non-drug methods and procedures to managing
pain and related health conditions including medical devices
approved or cleared by the Food and Drug Administration for
the treatment of patients with chronic pain and complementary
alternative medicines.
(C) Screening and identification of patients with substance
use disorder, including drug-seeking behavior, before
prescribing opioids, assessment of risk potential for
patients developing an addiction, and referral of patients to
appropriate addiction treatment professionals if addiction is
identified or strongly suspected.
(D) Communication with patients on the potential harm
associated with the use of opioids and other controlled
substances, including the need to safely store and dispose of
supplies relating to the use of opioids and other controlled
substances.
(E) Such other education and training as the Secretary
considers appropriate to ensure that veterans receive safe
and high-quality pain management care from the Department.
[[Page H2167]]
(3) Use of existing program.--In providing education and
training described in paragraph (2), the Secretary shall use
the Interdisciplinary Chronic Pain Management Training Team
Program of the Department (or success program).
(c) Pain Management Teams.--
(1) In general.--In carrying out the Opioid Safety
Initiative of the Department, the director of each medical
facility of the Department shall identify and designate a
pain management team of health care professionals, which may
include board certified pain medicine specialists,
responsible for coordinating and overseeing pain management
therapy at such facility for patients experiencing acute and
chronic pain that is non-cancer related.
(2) Establishment of protocols.--
(A) In general.--In consultation with the Directors of each
Veterans Integrated Service Network, the Secretary shall
establish standard protocols for the designation of pain
management teams at each medical facility within the
Department.
(B) Consultation on prescription of opioids.--Each protocol
established under subparagraph (A) shall ensure that any
health care provider without expertise in prescribing
analgesics or who has not completed the education and
training under subsection (b), including a mental health care
provider, does not prescribe opioids to a patient unless that
health care provider--
(i) consults with a health care provider with pain
management expertise or who is on the pain management team of
the medical facility; and
(ii) refers the patient to the pain management team for any
subsequent prescriptions and related therapy.
(3) Report.--
(A) In general.--Not later than one year after the date of
enactment of this Act, the director of each medical facility
of the Department shall submit to the Under Secretary for
Health and the director of the Veterans Integrated Service
Network in which the medical facility is located a report
identifying the health care professionals that have been
designated as members of the pain management team at the
medical facility pursuant to paragraph (1).
(B) Elements.--Each report submitted under subparagraph (A)
with respect to a medical facility of the Department shall
include--
(i) a certification as to whether all members of the pain
management team at the medical facility have completed the
education and training required under subsection (b);
(ii) a plan for the management and referral of patients to
such pain management team if health care providers without
expertise in prescribing analgesics prescribe opioid
medications to treat acute and chronic pain that is non-
cancer related; and
(iii) a certification as to whether the medical facility--
(I) fully complies with the stepped-care model of pain
management and other pain management policies contained in
Directive 2009-053 of the Veterans Health Administration, or
successor directive; or
(II) does not fully comply with such stepped-care model of
pain management and other pain management policies but is
carrying out a corrective plan of action to ensure such full
compliance.
(d) Tracking and Monitoring of Opioid Use.--
(1) Prescription drug monitoring programs of states.--In
carrying out the Opioid Safety Initiative and the Opioid
Therapy Risk Report tool of the Department, the Secretary
shall--
(A) ensure access by health care providers of the
Department to information on controlled substances, including
opioids and benzodiazepines, prescribed to veterans who
receive care outside the Department through the prescription
drug monitoring program of each State with such a program,
including by seeking to enter into memoranda of understanding
with States to allow shared access of such information
between States and the Department;
(B) include such information in the Opioid Therapy Risk
Report; and
(C) require health care providers of the Department to
submit to the prescription drug monitoring program of each
State information on prescriptions of controlled substances
received by veterans in that State under the laws
administered by the Secretary.
(2) Report on tracking of data on opioid use.--Not later
than 18 months after the date of the enactment of this Act,
the Secretary shall submit to the Committee on Veterans'
Affairs of the Senate and the Committee on Veterans' Affairs
of the House of Representatives a report on the feasibility
and advisability of improving the Opioid Therapy Risk Report
tool of the Department to allow for more advanced real-time
tracking of and access to data on--
(A) the key clinical indicators with respect to the
totality of opioid use by veterans;
(B) concurrent prescribing by health care providers of the
Department of opioids in different health care settings,
including data on concurrent prescribing of opioids to treat
mental health disorders other than opioid use disorder; and
(C) mail-order prescriptions of opioid prescribed to
veterans under the laws administered by the Secretary.
(e) Availability of Opioid Receptor Antagonists.--
(1) Increased availability and use.--
(A) In general.--The Secretary shall maximize the
availability of opioid receptor antagonists approved by the
Food and Drug Administration, including naloxone, to
veterans.
(B) Availability, training, and distributing.--In carrying
out subparagraph (A), not later than 90 days after the date
of the enactment of this Act, the Secretary shall--
(i) equip each pharmacy of the Department with opioid
receptor antagonists approved by the Food and Drug
Administration to be dispensed to outpatients as needed; and
(ii) expand the Overdose Education and Naloxone
Distribution program of the Department to ensure that all
veterans in receipt of health care under laws administered by
the Secretary who are at risk of opioid overdose may access
such opioid receptor antagonists and training on the proper
administration of such opioid receptor antagonists.
(C) Veterans who are at risk.--For purposes of subparagraph
(B), veterans who are at risk of opioid overdose include--
(i) veterans receiving long-term opioid therapy;
(ii) veterans receiving opioid therapy who have a history
of substance use disorder or prior instances of overdose; and
(iii) veterans who are at risk as determined by a health
care provider who is treating the veteran.
(2) Report.--Not later than 120 days after the date of the
enactment of this Act, the Secretary shall submit to the
Committee on Veterans' Affairs of the Senate and the
Committee on Veterans' Affairs of the House of
Representatives a report on carrying out paragraph (1),
including an assessment of any remaining steps to be carried
out by the Secretary to carry out such paragraph.
(f) Inclusion of Certain Information and Capabilities in
Opioid Therapy Risk Report Tool of the Department.--
(1) Information.--The Secretary shall include in the Opioid
Therapy Risk Report tool of the Department--
(A) information on the most recent time the tool was
accessed by a health care provider of the Department with
respect to each veteran; and
(B) information on the results of the most recent urine
drug test for each veteran.
(2) Capabilities.--The Secretary shall include in the
Opioid Therapy Risk Report tool the ability of the health
care providers of the Department to determine whether a
health care provider of the Department prescribed opioids to
a veteran without checking the information in the tool with
respect to the veteran.
(g) Notifications of Risk in Computerized Health Record.--
The Secretary shall modify the computerized patient record
system of the Department to ensure that any health care
provider that accesses the record of a veteran, regardless of
the reason the veteran seeks care from the health care
provider, will be immediately notified whether the veteran--
(1) is receiving opioid therapy and has a history of
substance use disorder or prior instances of overdose;
(2) has a history of opioid abuse; or
(3) is at risk of becoming an opioid abuser as determined
by a health care provider who is treating the veteran.
(h) Definitions.--In this section:
(1) The term ``controlled substance'' has the meaning given
that term in section 102 of the Controlled Substances Act (21
U.S.C. 802).
(2) The term ``State'' means each of the several States,
territories, and possessions of the United States, the
District of Columbia, and the Commonwealth of Puerto Rico.
SEC. 3. STRENGTHENING OF JOINT WORKING GROUP ON PAIN
MANAGEMENT OF THE DEPARTMENT OF VETERANS
AFFAIRS AND THE DEPARTMENT OF DEFENSE.
(a) In General.--Not later than 90 days after the date of
enactment of this Act, the Secretary of Veterans Affairs and
the Secretary of Defense shall ensure that the Pain
Management Working Group of the Health Executive Committee of
the Department of Veterans Affairs-Department of Defense
Joint Executive Committee (Pain Management Working Group)
established under section 320 of title 38, United States
Code, includes a focus on the following:
(1) The opioid prescribing practices of health care
providers of each Department.
(2) The ability of each Department to manage acute and
chronic pain among individuals receiving health care from the
Department, including training health care providers with
respect to pain management.
(3) The use by each Department of complementary and
integrative health and complementary alternative medicines in
treating such individuals.
(4) The concurrent use by health care providers of each
Department of opioids and prescription drugs to treat mental
health disorders, including benzodiazepines.
(5) The practice by health care providers of each
Department of prescribing opioids to treat mental health
disorders.
(6) The coordination in coverage of and consistent access
to medications prescribed for patients transitioning from
receiving health care from the Department of Defense to
receiving health care from the Department of Veterans
Affairs.
(7) The ability of each Department to identify and treat
substance use disorders among individuals receiving health
care from that Department.
[[Page H2168]]
(b) Coordination and Consultation.--The Secretary of
Veterans Affairs and the Secretary of Defense shall ensure
that the working group described in subsection (a)--
(1) coordinates the activities of the working group with
other relevant working groups established under section 320
of title 38, United States Code;
(2) consults with other relevant Federal agencies with
respect to the activities of the working group; and
(3) consults with the Department of Veterans Affairs and
the Department of Defense with respect to, reviews, and
comments on the VA/DOD Clinical Practice Guideline for
Management of Opioid Therapy for Chronic Pain, or any
successor guideline, before any update to the guideline is
released.
(c) Clinical Practice Guidelines.--
(1) In general.--Not later than 180 days after the date of
the enactment of this Act, the Secretary of Veterans Affairs
and the Secretary of Defense shall issue an update to the VA/
DOD Clinical Practice Guideline for Management of Opioid
Therapy for Chronic Pain.
(2) Matters included.--In conducting the update under
subsection (a), the Pain Management Working Group, in
coordination with the Clinical Practice Guideline VA/DoD
Management of Opioid Therapy for Chronic Pain Working Group,
shall examine whether the Clinical Practical Guideline should
include the following:
(A) Enhanced guidance with respect to--
(i) the coadministration of an opioid and other drugs,
including benzodiazepines, that may result in life-limiting
drug interactions;
(ii) the treatment of patients with current acute
psychiatric instability or substance use disorder or patients
at risk of suicide; and
(iii) the use of opioid therapy to treat mental health
disorders other than opioid use disorder.
(B) Enhanced guidance with respect to the treatment of
patients with behaviors or comorbidities, such as post-
traumatic stress disorder or other psychiatric disorders, or
a history of substance abuse or addiction, that requires a
consultation or comanagement of opioid therapy with one or
more specialists in pain management, mental health, or
addictions.
(C) Enhanced guidance with respect to health care
providers--
(i) conducting an effective assessment for patients
beginning or continuing opioid therapy, including
understanding and setting realistic goals with respect to
achieving and maintaining an expected level of pain relief,
improved function, or a clinically appropriate combination of
both; and
(ii) effectively assessing whether opioid therapy is
achieving or maintaining the established treatment goals of
the patient or whether the patient and health care provider
should discuss adjusting, augmenting , or discontinuing the
opioid therapy.
(D) Guidelines to govern the methodologies used by health
care providers of the Department of Veterans Affairs and the
Department of Defense to taper opioid therapy when adjusting
or discontinuing the use of opioid therapy.
(E) Guidelines with respect to appropriate case management
for patients receiving opioid therapy who transition between
inpatient and outpatient health care settings, which may
include the use of care transition plans.
(F) Guidelines with respect to appropriate case management
for patients receiving opioid therapy who transition from
receiving care during active duty to post-military health
care networks.
(G) Guidelines with respect to providing options, before
initiating opioid therapy, for pain management therapies
without the use of opioids and options to augment opioid
therapy with other clinical and complementary and integrative
health services to minimize opioid dependence.
(H) Guidelines with respect to the provision of evidence-
based non-opioid treatments within the Department of Veterans
Affairs and the Department of Defense, including medical
devices and other therapies approved or cleared by the Food
and Drug Administration for the treatment of chronic pain as
an alternative to or to augment opioid therapy.
SEC. 4. REVIEW, INVESTIGATION, AND REPORT ON USE OF OPIOIDS
IN TREATMENT BY DEPARTMENT OF VETERANS AFFAIRS.
(a) Comptroller General Report.--
(1) In general.--Not later than two years after the date of
the enactment of this Act, the Comptroller General of the
United States shall submit to the Committee on Veterans'
Affairs of the Senate and the Committee on Veterans' Affairs
of the House of Representatives a report on the Opioid Safety
Initiative of the Department of Veterans Affairs and the
opioid prescribing practices of health care providers of the
Department.
(2) Elements.--The report submitted under paragraph (1)
shall include the following:
(A) Recommendations on such improvements to the Opioid
Safety Initiative of the Department as the Comptroller
General considers appropriate.
(B) Information with respect to--
(i) deaths resulting from sentinel events involving
veterans prescribed opioids by a health care provider of the
Department;
(ii) overall prescription rates and prescriptions
indications of opioids to treat non-cancer, non-palliative,
and non-hospice care patients;
(iii) the prescription rates and prescriptions indications
of benzodiazepines and opioids concomitantly by health care
providers of the Department;
(iv) the practice by health care providers of the
Department of prescribing opioids to treat patients without
any pain, including to treat patients with mental health
disorders other than opioid use disorder; and
(v) the effectiveness of opioid therapy for patients
receiving such therapy, including the effectiveness of long-
term opioid therapy.
(C) An evaluation of processes of the Department in place
to oversee opioid use among veterans, including procedures to
identify and remedy potential over-prescribing of opioids by
health care providers of the Department.
(D) An assessment of the implementation by the Secretary of
the VA/DOD Clinical Practice Guideline for Management of
Opioid Therapy for Chronic Pain.
(b) Quarterly Progress Report on Implementation of
Comptroller General Recommendations.--Not later than two
years after the date of the enactment of this Act, and not
later than 30 days after the end of each quarter thereafter,
the Secretary of Veterans Affairs shall submit to the
Committee on Veterans' Affairs of the Senate and the
Committee on Veterans' Affairs of the House of
Representatives a progress report detailing the actions by
the Secretary during the period covered by the report to
address any outstanding findings and recommendations by the
Comptroller General of the United States under subsection (a)
with respect to the Veterans Health Administration.
(c) Annual Review of Prescription Rates.--Not later than
one year after the date of the enactment of this Act, and not
less frequently than annually for the following five years,
the Secretary shall submit to the Committee on Veterans'
Affairs of the Senate and the Committee on Veterans' Affairs
of the House of Representatives a report, with respect to
each medical facility of the Department of Veterans Affairs,
to collect and review information on opioids prescribed by
health care providers at the facility to treat non-cancer,
non-palliative, and non-hospice care patients that contains,
for the one-year period preceding the submission of the
report, the following:
(1) The number of patients and the percentage of the
patient population of the Department who were prescribed
benzodiazepines and opioids concurrently by a health care
provider of the Department.
(2) The number of patients and the percentage of the
patient population of the Department without any pain who
were prescribed opioids by a health care provider of the
Department, including those who were prescribed
benzodiazepines and opioids concurrently.
(3) The number of non-cancer, non-palliative, and non-
hospice care patients and the percentage of such patients who
were treated with opioids by a health care provider of the
Department on an inpatient-basis and who also received
prescription opioids by mail from the Department while being
treated on an inpatient-basis.
(4) The number of non-cancer, non-palliative, and non-
hospice care patients and the percentage of such patients who
were prescribed opioids concurrently by a health care
provider of the Department and a health care provider that is
not health care provider of the Department.
(5) With respect to each medical facility of the
Department, information on opioids prescribed by health care
providers at the facility to treat non-cancer, non-
palliative, and non-hospice care patients, including
information on--
(A) the prescription rate at which each health care
provider at the facility prescribed benzodiazepines and
opioids concurrently to such patients and the aggregate such
prescription rate for all health care providers at the
facility;
(B) the prescription rate at which each health care
provider at the facility prescribed benzodiazepines or
opioids to such patients to treat conditions for which
benzodiazepines or opioids are not approved treatment and the
aggregate such prescription rate for all health care
providers at the facility;
(C) the prescription rate at which each health care
provider at the facility prescribed or dispensed mail-order
prescriptions of opioids to such patients while such patients
were being treated with opioids on an inpatient-basis and the
aggregate of such prescription rate for all health care
providers at the facility; and
(D) the prescription rate at which each health care
provider at the facility prescribed opioids to such patients
who were also concurrently prescribed opioids by a health
care provider that is not a health care provider of the
Department and the aggregate of such prescription rates for
all health care providers at the facility.
(6) With respect to each medical facility of the
Department, the number of times a pharmacist at the facility
overrode a critical drug interaction warning with respect to
an interaction between opioids and another medication before
dispensing such medication to a veteran.
(d) Investigation of Prescription Rates.--If the Secretary
determines that a prescription rate with respect to a health
care provider or medical facility of the Department conflicts
with or is otherwise inconsistent with the standards of
appropriate and safe care, the Secretary shall--
[[Page H2169]]
(1) immediately notify the Committee on Veterans' Affairs
of the Senate and the Committee on Veterans' Affairs of the
House of Representatives of such determination, including
information relating to such determination, prescription
rate, and health care provider or medical facility, as the
case may be; and
(2) through the Office of the Medical Inspector of the
Veterans Health Administration, conduct a full investigation
of the health care provider or medical facility, as the case
may be.
(e) Prescription Rate Defined.--In this section, the term
``prescription rate'' means, with respect to a health care
provider or medical facility of the Department, each of the
following:
(1) The number of patients treated with opioids by the
health care provider or at the medical facility, as the case
may be, divided by the total number of pharmacy users of that
health care provider or medical facility.
(2) The average number of morphine equivalents per day
prescribed by the health care provider or at the medical
facility, as the case may be, to patients being treated with
opioids.
(3) Of the patients being treated with opioids by the
health care provider or at the medical facility, as the case
may be, the average number of prescriptions of opioids per
patient.
SEC. 5. MANDATORY DISCLOSURE OF CERTAIN VETERAN INFORMATION
TO STATE CONTROLLED SUBSTANCE MONITORING
PROGRAMS.
Section 5701(l) of title 38, United States Code, is amended
by striking ``may'' and inserting ``shall''.
SEC. 6. MODIFICATION TO LIMITATION ON AWARDS AND BONUSES.
Section 705 of the Veterans Access, Choice, and
Accountability Act of 2014 (Public Law 113-146; 38 U.S.C. 703
note) is amended to read as follows:
``SEC. 705. LIMITATION ON AWARDS AND BONUSES PAID TO
EMPLOYEES OF DEPARTMENT OF VETERANS AFFAIRS.
``The Secretary of Veterans Affairs shall ensure that the
aggregate amount of awards and bonuses paid by the Secretary
in a fiscal year under chapter 45 or 53 of title 5, United
States Code, or any other awards or bonuses authorized under
such title or title 38, United States Code, does not exceed
the following amounts:
``(1) With respect to each of fiscal years 2017 through
2021, $230,000,000.
``(2) With respect to each of fiscal years 2022 through
2024, $360,000,000.''.
The SPEAKER pro tempore. Pursuant to the rule, the gentleman from
Florida (Mr. Miller) and the gentleman from North Carolina (Mr.
Butterfield) each will control 20 minutes.
The Chair recognizes the gentleman from Florida.
General Leave
Mr. MILLER of Florida. Mr. Speaker, I ask unanimous consent that all
Members have 5 legislative days in which to revise and extend or add
any extraneous material to their remarks.
The SPEAKER pro tempore. Is there objection to the request of the
gentleman from Florida?
There was no objection.
Mr. MILLER of Florida. Mr. Speaker, I yield myself such time as I may
consume.
Mr. Speaker, I rise today in support of H.R. 4063, as amended, the
Promoting Responsible Opioid Management and Incorporating Scientific
Expertise--or the Jason Simcakoski PROMISE--Act.
When our Nation's servicemembers transition from military life to
civilian life, they carry with them the skills, experiences, memories,
and relationships that will last a lifetime. Unfortunately, many of
them also carry significant pain as a result of injuries that they
incurred while in service to this great Nation.
Veterans, in general, experience chronic pain at a higher rate than
their nonveteran counterparts. What is more, chronic pain is one of the
most frequent conditions facing the veterans of Iraq and Afghanistan.
Effectively managing this pain, which often occurs alongside a number
of other comorbid conditions, is a challenge for which the Department
of Veterans Affairs has been increasingly turning to opioid-based
medications to meet that challenge.
Now, while opioids, when used appropriately, can be effective in
treating pain, opioid medications are extremely high risk.
Unfortunately, VA's own research has found that veterans are at an
increased risk for many adverse outcomes that may accompany opioid use,
including substance abuse, overdose, and self-inflicted injuries.
Given that, VA's recent reliance on opioid medications to manage
veteran pain is alarming. According to a CBS News report on VA data,
the number of opioid prescriptions written by VA providers rose an
astonishing 259 percent from 2002 to 2013. During that same time
period, VA's total patient population increased only 29 percent.
The sad reality behind an overreliance on opioids became apparent at
the VA Medical Center at Tomah, Wisconsin, last year. In response to a
series of complaints made in 2011 and 2012, the VA Office of the
Inspector General conducted a review of alleged inappropriate
prescribing of controlled substances and abuse of authority at the
Tomah VA Medical Center. The IG found that the number of opioids
prescribed in Tomah was ``at considerable variance'' with the other VA
medical facilities in that region and was a cause for ``potentially
serious concerns.''
{time} 1545
It is no wonder that the veterans being treated in Tomah commonly
referred to it as ``Candy Land'' and to the facility chief of staff as
the ``Candy Man.'' Jason Simcakoski was one veteran who was being
treated by the Tomah VA Medical Center.
In August of 2014, Jason died from the combined effect of the
multiple prescription medications he received as an in-patient. He put
his trust in a system that ultimately failed him.
He left behind a young daughter and a grieving family, some of whom
are with us today. Unfortunately, the failures in Tomah, the failures
that led to Jason's death, are not isolated. There are countless others
just like him in the VA across this country.
Chronic pain and the conditions that frequently accompany it are
undoubtedly complex, and concerns about an overreliance on opioids are
certainly not unique to the Department of Veterans Affairs.
But the VA alone has the responsibility to treat our Nation's most
heroic citizens, meaning VA does have a unique responsibility to act
responsibly.
The bill before us would help the Department do just that by
improving and expanding opioid safety initiatives, strengthening the
VA/Department of Defense joint working group on pain management,
mandating that VA medical facilities disclose information to State-
controlled substance monitoring programs, and requiring VA review,
investigate, and report on the use of opioids among veteran patients.
The manager's amendment to H.R. 4063 would require the Department and
DOD to update their joint clinical practice guidelines for the
management of opioid therapy to reflect the latest medical practices.
The bill would also direct VA to ensure that every employee who
prescribes opioids receives education and training on pain management
and safe prescribing practices and every VA medical facility has a
designated pain management team.
It would further require VA to maximize the availability of Food and
Drug Administration-approved opioid receptor antagonists to ensure that
veterans most at risk of opioid overdose have access to and training on
potentially life-saving drugs that can counter the devastating effects
of an opioid overdose.
I am grateful to the vice chairman of the full Veterans' Affairs
Committee, Gus Bilirakis, for sponsoring this legislation. I urge all
of my colleagues to join me in supporting it.
I reserve the balance of my time.
Committee on Armed Services,
House of Representatives,
Washington, DC, May 9, 2016.
Hon. Jeff Miller,
Chairman, Committee on Veterans' Affairs,
House of Representatives, Washington, DC.
Dear Mr. Chairman: I am writing to you concerning the bill
H.R. 4063, the Jason Simcakoski PROMISE Act. There are
certain provisions in the legislation which fall within the
Rule X jurisdiction of the Committee on Armed Services.
In the interest of permitting your committee to proceed
expeditiously to floor consideration of this important bill,
I am willing to waive this committee's right to sequential
referral. I do so with the understanding that by waiving
consideration of the bill the Committee on Armed Services
does not waive any future jurisdictional claim over the
subject matters contained in the bill which fall within its
Rule X jurisdiction. I request that you urge the Speaker to
name members of this committee to any conference committee
which is named to consider such provisions.
Please place this letter into the committee report on H.R.
4063 and into the Congressional Record during consideration
of the
[[Page H2170]]
measure on the House floor. Thank you for the cooperative
spirit in which you have worked regarding this matter and
others between our respective committees.
Sincerely,
William M. ``Mac'' Thornberry,
Chairman.
____
House of Representatives,
Committee on Veterans' Affairs,
Washington, DC, May 10, 2016.
Hon. William M. ``Mac'' Thornberry,
Chairman, Committee on Armed Services,
House of Representatives, Washington, DC.
Dear Mr. Chairman, Thank you for your letter regarding H.R.
4063, as amended, the Jason Simcakoski PROMISE Act.
I agree that the Committee on Armed Services has valid
jurisdictional claims to certain provisions in this
legislation and I appreciate your decision not to request a
referral in the interest of expediting consideration of the
bill.
I agree that by foregoing a sequential referral to H.R.
4063, as amended, the Committee on Armed Services is not
waiving its jurisdiction.
This exchange of letters will be included in the
Committee's report on H.R. 4063, as amended.
If you have any further questions or concerns, please
contact Christine Hill, Staff Director for the Subcommittee
on Health.
Thank you for your commitment to the well-being of our
nation's veterans.
With warm personal regards, I am,
Sincerely,
Jeff Miller,
Chairman.
Mr. BUTTERFIELD. Mr. Speaker, I yield myself such time as I may
consume.
Mr. Speaker, I rise today in support of H.R. 4063, as amended, the
Jason Simcakoski PROMISE Act.
I would like to thank my friend from Florida, the vice chair of the
committee, Congressman Gus Bilirakis, for introducing this bill and for
his passionate leadership on this very important issue.
Mr. Speaker, I also would like to take a moment to thank Chairman
Miller for his extraordinary leadership on this bill and on issues that
pertain to veterans generally. I thank the chairman so much for all of
his work. In fact, the rumor among our colleagues is that he runs the
most bipartisan committee on Capitol Hill. I thank him for his
leadership.
The epidemic of opioid addiction and overdose deaths is a national
problem. It is a public health crisis, Mr. Speaker, that affects
constituents living in all of our districts and all of our States.
Opioid use disorder is a chronic relapsing disease of the brain. Yet,
the stigma associated with opioid use disorder keeps people from
seeking, accessing, or maintaining treatment.
In 2014, according to The New York Times, over 47,000 people died
from a drug overdose. That is 125 Americans each day who lost their
lives due to addiction or abuse. Of these, more than 61 percent
involved opioids.
Across the country, Mr. Speaker, nearly 260 million prescriptions are
written for opioids, enough, according to the Centers for Disease
Control, for every American adult to have their own bottle of pills
that can be highly, highly addictive.
In my home State of North Carolina, fatal drug overdoses have jumped
75 percent since 2002. According to an article in February from The
Charlotte Observer, nearly half of the accidental drug overdose deaths
in 2010 were associated with prescriptions that had been filled within
60 days of death.
It is estimated that North Carolina has spent over $582 million in
healthcare costs stemming from opioid abuse. This is nearly $59 for
each man, woman, and child in my home State of North Carolina. This is
a healthcare problem, Mr. Speaker, that affects all levels of our
society. One of the main drivers is the overprescription of opioids to
manage pain.
Veterans are at an even greater risk. The statistics on veterans
experiencing chronic pain are absolutely staggering. Over 50 percent of
all veterans enrolled and receiving care at VA medical facilities
experience chronic pain, with over half a million veterans managing
pain with prescribed opioids. Compared to the general population,
veterans are prescribed opioids at a much, much higher rate.
But there is a growing awareness that the long-term prescription of
opioids to manage chronic pain can have severe and sometimes tragic--
yes, tragic--consequences. It has been reported that veterans, our
beloved veterans, are twice as likely to die from accidental overdose
compared to nonveterans.
As a Member of Congress that represents the ``Nation's Most Military
Friendly State''--and we like to say that all of the time--and as an
Army veteran, as I am myself, I am alarmed and committed to bringing
about a solution.
But addressing this crisis will not be easy. The Veterans' Affairs
Committee members know that so very well. It is not going to be easy.
It will take the work of all of us working together. It will take
education. It will take research into more effective and less addictive
ways to treat chronic pain.
It will take the combined work, Mr. Speaker, of our States and the
Federal Government to address what the CDC has termed ``the worst drug
addiction epidemic in the country's history,'' and the chief medical
officer of my State's medical board has called it ``an unequivocal
health crisis.''
This bill, Mr. Speaker, we are debating today marks a major step
forward, and it will go a very long way in helping to lessen this
public health emergency.
Mr. Speaker, I reserve the balance of my time.
Mr. MILLER of Florida. Mr. Speaker, I yield 5 minutes to the
gentleman from Florida (Mr. Bilirakis) of the 12th District of Florida,
the vice chairman of the full committee, somebody who has been a
stalwart on this and many other veteran issues.
Mr. BILIRAKIS. Mr. Speaker, I thank the chairman and the ranking
member. I appreciate it.
I rise in support of my bill, H.R. 4063, the Promoting Responsible
Opioid Management and Incorporating Scientific Expertise, or the Jason
Simcakoski PROMISE Act.
This important bill helps us fulfill our promise to past, current,
and future veterans, our true American heroes, Mr. Speaker.
I introduced the PROMISE Act in response to the tragic death of
Marine Corps Corporal Jason Simcakoski at the Tomah, Wisconsin, VA
Medical Center.
Jason's death, caused by a mixed drug toxicity and the combination of
various medications, was an avoidable tragedy. My colleagues and I
worked with local veterans, veterans organizations, and other
stakeholders to get this done right.
I am honored to discuss the need for this bill in the presence of
Jason's family, who join us in the Capitol on this memorable day. We
could not do it without them.
The PROMISE Act can't bring Jason and others like him back. But, like
Jason's family expressed to me, this will ensure future veterans get
the treatment they need for their physical and invisible wounds.
Currently, VA treatment for chronic pain is largely the prescription
of opioids without consideration of a patient's personal history or
preferences. Unfortunately, there is a lack of data on veteran opioid
use. There are also inefficiencies in the VA identifying abuse of
opioids and with patient follow-up to determine effectiveness of these
drugs on a case-by-case basis.
The PROMISE Act is the congressional action needed to rectify these
problems. The PROMISE Act increases safety for opioid therapy and pain
management, ensures more transparency at the VA, and encourages more
outreach and awareness of the patient advocacy program for veterans.
My bill also acknowledges that VA patient services do not stop at the
initial consultation. It requires the VA to maintain realtime tracking
of data on opioid use to help prevent overmedication and misuse or
overuse of medication.
I want to thank Speaker Ryan; Representative Butterfield, of course;
our great chairman, Mr. Miller from Florida, a real good friend of
mine; Representative Kind, Representative Rice, and many others who
supported this bill and worked to make this happen.
I urge my colleagues to support this bill to uphold our commitment
and promise to those that pay the ultimate sacrifice.
Mr. BUTTERFIELD. Mr. Speaker, I yield such time as he may consume to
the gentleman from Wisconsin (Mr. Kind), and I thank Mr. Kind for
coming to the floor. There is not a Member of this body who works
harder than him on issues that pertain to veterans.
[[Page H2171]]
(Mr. KIND asked and was given permission to revise and extend his
remarks.)
Mr. KIND. Mr. Speaker, I thank my good friend from North Carolina for
yielding me this time.
Mr. Speaker, I rise in strong support of the Jason Simcakoski PROMISE
Act.
Jason was a veteran who unfortunately saw his life end way too soon
while receiving treatment at the Tomah VA Medical Center in the heart
of my congressional district.
I want to thank, first of all, Subcommittee Chairman Bilirakis for
the leadership and support that he has shown this legislation. He has
been a real joy to work with.
I want to thank Chairman Miller for the leadership he has provided
the committee and for the concern and the attention that he has given
to all of our veterans throughout our country.
I want to thank Representative Butterfield and the other members of
the committee for the strong bipartisan support that this legislation
enjoys on the floor today.
Jason was born in Stevens Point, Wisconsin, in 1978 in my
congressional district. He is the son of Marvin and Linda Simcakoski.
He is a graduate of Stevens Point Pacelli High School.
Shortly after his graduation, he joined the Marine Corps, where he
reached the rank of corporal, receiving the Sea Service Deployment
Ribbon with one star, a Certificate of Commendation, the Rifle Sharp
Shooters Badge, and the Good Conduct Medal. He was honorably discharged
in February of 2002. Jason loved being a marine, and he was very proud
to serve his country.
He married Heather in 2010 in Stevens Point, and they had a beautiful
daughter named Anaya. I am proud that many members of Jason's family
came out to Washington this week to see the passage of this bill today:
his mother Linda, his wife Heather, his daughter Anaya, who are in the
Chamber with us today. His father, Marvin, who was also intimately
involved in helping draft this legislation and see it through, was
unfortunately unable to attend.
But I commend all of them because this is how legislation is meant to
work, by reaching out to veterans organizations, getting direct
feedback from the veterans themselves, their families, healthcare
providers. We have known for some time that we have had a pain
management problem not just in the VA medical system, but throughout
our entire healthcare system.
This unfortunately came to light through numerous investigations at
the Tomah VA Medical Center over the course of the last few years,
which ultimately helped and precipitated the legislation that we have
before us today.
{time} 1600
Jason's family's guiding star in all of this, based on the numerous
conversations that I have had with them and that they have had with
Chairman Bilirakis and even with Speaker Ryan, was to ensure that the
care and the treatment that our veterans receive be enhanced so that no
veteran and no family would have to go through and endure what they
did.
Jason was receiving pain management and was under the opioid
medication at Tomah. This legislation, I think, advances that goal. I
don't think anyone can be here with absolute certitude and promise a
family or future veterans that mistakes won't happen in the future; but
I think what is contained in this legislation is a significant step in
the right direction, with the understanding that more work is needed.
The bill would require a review and an update of the VA's Clinical
Practice Guideline for the Management of Opioid Therapy for Chronic
Pain. It requires all opioid prescribers at the VA to have enhanced
pain management and safe opioid prescribing education and training. It
improves the realtime tracking of and access to data on the opioid use
of veterans in order to prevent overmedication. It provides additional
resources to assist the VA's ability to counter overdoses. It expands
the Opioid Safety Initiative to all VA medical facilities. It updates
the Joint Working Group of the VA and DOD to focus on opioid
prescribing practices, the use of alternative pain therapy, and the
coordination when a servicemember transitions from the DOD into the VA
care setting. It also encourages the use of alternative and
complementary forms of pain management. Lastly, it requires the VA to
report on prescription rates so we can better assess the problem and
find solutions.
This is a work in progress not just within the VA system, not just
with the reforms that are currently being implemented at the Tomah VA
Medical Center in my congressional district, but throughout the entire
healthcare system. We as a Nation have not done a very good job of
managing pain at all levels. I am glad and I am proud that this
Congress sees the need to move forward on a comprehensive opioid
legislation bill. Hopefully we can get that to the finish line yet this
year. There is also a major VA reform bill that we are working on--
excellent vehicles in order to include some of the provisions of this
legislation as we move forward.
If there is any hope and promise that out of the tragedy of Jason's
death good things can come of it, I think the legislation that we have
before us today, the Jason Simcakoski PROMISE Act, gives us that hope
and gives us that opportunity. I couldn't think of a more powerful
legacy in Jason's name than this legislation.
I ask all of my colleagues to give their support of this legislation
today. Again, I thank the leadership of the Committee on Veterans'
Affairs for the help, the assistance, and the focus that they have
provided on this important piece of legislation.
The SPEAKER pro tempore. Members are reminded that it is not in order
to introduce to the House individuals present in the gallery.
Mr. MILLER of Florida. Mr. Speaker, I yield 2 minutes to the
gentleman from Georgia (Mr. Carter).
Mr. CARTER of Georgia. I thank the gentleman from Florida for
yielding and for his efforts and the efforts of all of those who are
involved in this legislation.
Mr. Speaker, my concern here is twofold. First of all, as a
pharmacist with over 30 years of experience and practice, this is a
deep concern of mine.
Secondly, I believe we have a duty to our servicemen and -women who
have sacrificed their lives to serve and protect our country. Studies
have shown that soldiers and veterans use opioid painkillers far more
frequently than civilians because their military training and combat
lead to far more injuries. In fact, a report by the American Public
Health Association found that the fatal overdose rate among VA patients
is nearly double the national average. Something needs to be done. The
VA is doing a disservice to our veterans by prescribing too many
opioids at too high quantities. That is why H.R. 4063 is so important.
H.R. 4063 directs the Department of Defense and the Department of
Veterans Affairs to jointly update the VA/DOD Clinical Practice
Guideline for the Management of Opioid Therapy for Chronic Pain so it
adequately reflects the current environment we face with opioid abuse.
It also directs the VA to modify and establish initiatives and
protocols to better address the misuse of opioids by our veterans.
These changes, I believe, will be one step toward ensuring that the
services provided to our men and women of the military will improve
their overall care and will move us closer to fulfilling our duty of
servicing our servicemen and -women.
I ask all of my colleagues to support this legislation.
Mr. BUTTERFIELD. Mr. Speaker, I yield myself such time as I may
consume.
It is bipartisan legislation like this that makes me proud to be a
Member of the United States Congress. I want to thank each one of my
colleagues for his role in making this day happen.
I thank Jason's family. I am not going to single them out except to
make reference to them. I just want to thank Jason's family for making
the journey to Washington today for this very important and momentous
occasion.
Mr. Speaker, I yield back the balance of my time.
Mr. MILLER of Florida. Mr. Speaker, I yield myself such time as I may
consume.
I wish that we did not have to discuss this tragedy today on the
floor. Jake is not with us, not by his choice. His wife is a widow; his
daughter is now fatherless; his parents lost a son.
[[Page H2172]]
Why? Why did he die of a drug overdose inside of the very hospital in
which he sought protection?
Mr. Speaker, I hope that all Members will support this legislation
today. It is not that it will bring Jake back, but it may prevent this
from occurring to another veteran in the future.
I yield back the balance of my time.
Ms. JACKSON LEE. Mr. Speaker, I rise in strong support of H.R. 4063,
the ``Promise Act.''
H.R. 4063 directs the Department of Veterans Affairs (VA) and the
Department of Defense (DOD) to jointly update their respective clinical
practice guidelines.
The practice guideline pertains to the management of Opioid Therapy
for Chronic Pain.
The guidelines spell out procedures for: (1) prescribing opioids for
outpatient treatment, (2) (con-tra-in-di-ca-tions) contraindications
for opioid therapy, (3) treatment of patients with post-traumatic
stress disorder, (4) psychiatric disorders, or a history of substance
abuse or addiction, (5) and management transitioning patients.
The guidelines also prescribe routine and random urine drug tests, as
well as treatment options to augment opioid therapy designed to
minimize opioid dependence.
This bill examines the VA's evidence-based therapy treatment model
for treating veterans' mental health conditions.
The Department of Veterans Affairs (VA) will be expected to update
safety measures for opioid therapy, expand the use of alternative
medicine, and conduct audits of the VA health care system through a
nongovernment entity.
The VA will be required to request documentation of medical license
violations during the past 20 years and any settlement agreements for
medical-related disciplinary charges from the medical board, of each
state.
All VA medical facilities will implement the opioid safety initiative
and train employees to effectively dispense pain management techniques
through the establishment of pain management teams.
Enhancing national oversight, the VA is also expected to track and
monitor opioid use and access to state program information, increase
the availability of Food and Drug Administration-approved opioid
receptor antagonists, and modify the computerized patient record
system, as well as internal audits.
Adjusting the computerized patient record system will ensure that
health care providers accessing veterans' records are notified of their
use of opioid therapy.
This system also informs health care providers of substance use
disorder or opioid abuse histories.
The Promise Act of 2016 institutes pilot programs within the VA to
evaluate the feasibility of wellness programs complementing veteran
pain management and related health care services.
I support this legislation because it will promote safety measures
for opioid therapy and alternative medicine.
H.R. 4063 is a positive step in the right direction and I urge my
colleagues to join me in supporting its passage.
Mrs. LAWRENCE. Mr. Speaker, I stand today in support of H.R. 4063,
the Jason Simcakoski PROMISE Act. As those who defend our liberty
return home from service, their fight for freedom internalizes. The
homecoming of our nation's veterans often marks their entrance into a
new war--a constant battle against a visceral and intangible enemy:
substance abuse. As we pass this important legislation, we afford our
veterans the adequate support to fight this uphill battle, thus
allowing our nation's fallen soldiers to rise as they repeatedly repel
attacks from addiction. We must pass the PROMISE Act, because if we do
not look out for the protectors of our freedom, who will look out for
us?
Through my experiences as an EOE investigator at the USPS, I saw
firsthand the divisive consequences of substance abuse on addicts,
their loved ones, and communities as a whole. The PROMISE Act will
bring nationwide uniformity to opioid addiction prevention efforts by
implementing opioid treatment and therapy guidelines, expanding VA
safety initiatives, and establishing research-based committees to
measure the quality of treatment methods. While some may question why
we are voting today to help those who have broken our nation's laws,
just consider: who were the citizens that protected our freedom and
nurtured our liberty when they were called upon? Now that our soldiers
are the ones in need, who are we to deny them?
Just as veterans took on the duty of defending our communities, we
must come together to halt the increasing opioid addiction rate for the
sake of veterans and the good of America as a whole. The PROMISE Act
will serve to acknowledge veterans' selfless sacrifice by establishing
a forgotten American ideal: that we as a nation will always care for
those who protect and defend our freedom. While no amount of money
could ever buy back that which was sacrificed in the name of liberty,
the passage of this legislation will alleviate some of the hardships
faced by opioid-dependent veterans. As we look to find the most
effective methods for treating opioid addiction, the PROMISE Act will
serve as a strong step toward reversing our nation's substance abuse
epidemic.
The SPEAKER pro tempore. The question is on the motion offered by the
gentleman from Florida (Mr. Miller) that the House suspend the rules
and pass the bill, H.R. 4063, as amended.
The question was taken; and (two-thirds being in the affirmative) the
rules were suspended and the bill, as amended, was passed.
The title of the bill was amended so as to read: ``A bill to improve
the use by the Secretary of Veterans Affairs of opioids in treating
veterans, and for other purposes.''.
A motion to reconsider was laid on the table.
____________________