[Congressional Record (Bound Edition), Volume 162 (2016), Part 4]
[House]
[Pages 5587-5593]
[From the U.S. 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.
       (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.--

[[Page 5588]]

       (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

[[Page 5589]]

     individuals receiving health care from that Department.
       (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

[[Page 5590]]

     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--
       (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

[[Page 5591]]

     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 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.

[[Page 5592]]

  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.
  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

[[Page 5593]]

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.
  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.

                          ____________________