[House Hearing, 114 Congress]
[From the U.S. Government Publishing Office]





    WHAT ARE THE STATE GOVERNMENTS DOING TO COMBAT THE OPIOID ABUSE 
                               EPIDEMIC?

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

                                HEARING

                               BEFORE THE

              SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

                                 OF THE

                    COMMITTEE ON ENERGY AND COMMERCE
                        HOUSE OF REPRESENTATIVES

                    ONE HUNDRED FOURTEENTH CONGRESS

                             FIRST SESSION

                               __________

                              MAY 21, 2015

                               __________

                           Serial No. 114-46



[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]




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                    COMMITTEE ON ENERGY AND COMMERCE

                          FRED UPTON, Michigan
                                 Chairman

JOE BARTON, Texas                    FRANK PALLONE, Jr., New Jersey
  Chairman Emeritus                    Ranking Member
ED WHITFIELD, Kentucky               BOBBY L. RUSH, Illinois
JOHN SHIMKUS, Illinois               ANNA G. ESHOO, California
JOSEPH R. PITTS, Pennsylvania        ELIOT L. ENGEL, New York
GREG WALDEN, Oregon                  GENE GREEN, Texas
TIM MURPHY, Pennsylvania             DIANA DeGETTE, Colorado
MICHAEL C. BURGESS, Texas            LOIS CAPPS, California
MARSHA BLACKBURN, Tennessee          MICHAEL F. DOYLE, Pennsylvania
  Vice Chairman                      JANICE D. SCHAKOWSKY, Illinois
STEVE SCALISE, Louisiana             G.K. BUTTERFIELD, North Carolina
ROBERT E. LATTA, Ohio                DORIS O. MATSUI, California
CATHY McMORRIS RODGERS, Washington   KATHY CASTOR, Florida
GREGG HARPER, Mississippi            JOHN P. SARBANES, Maryland
LEONARD LANCE, New Jersey            JERRY McNERNEY, California
BRETT GUTHRIE, Kentucky              PETER WELCH, Vermont
PETE OLSON, Texas                    BEN RAY LUJAN, New Mexico
DAVID B. McKINLEY, West Virginia     PAUL TONKO, New York
MIKE POMPEO, Kansas                  JOHN A. YARMUTH, Kentucky
ADAM KINZINGER, Illinois             YVETTE D. CLARKE, New York
H. MORGAN GRIFFITH, Virginia         DAVID LOEBSACK, Iowa
GUS M. BILIRAKIS, Florida            KURT SCHRADER, Oregon
BILL JOHNSON, Ohio                   JOSEPH P. KENNEDY, III, 
BILLY LONG, Missouri                 Massachusetts
RENEE L. ELLMERS, North Carolina     TONY CARDENAS, California
LARRY BUCSHON, Indiana
BILL FLORES, Texas
SUSAN W. BROOKS, Indiana
MARKWAYNE MULLIN, Oklahoma
RICHARD HUDSON, North Carolina
CHRIS COLLINS, New York
KEVIN CRAMER, North Dakota

                                 _____

              Subcommittee on Oversight and Investigations

                        TIM MURPHY, Pennsylvania
                                 Chairman
DAVID B. McKINLEY, West Virginia     DIANA DeGETTE, Colorado
  Vice Chairman                        Ranking Member
MICHAEL C. BURGESS, Texas            JANICE D. SCHAKOWSKY, Illinois
MARSHA BLACKBURN, Tennessee          KATHY CASTOR, Florida
H. MORGAN GRIFFITH, Virginia         PAUL TONKO, New York
LARRY BUCSHON, Indiana               JOHN A. YARMUTH, Kentucky
BILL FLORES, Texas                   YVETTE D. CLARKE, New York
SUSAN W. BROOKS, Indiana             JOSEPH P. KENNEDY, III, 
MARKWAYNE MULLIN, Oklahoma               Massachusetts
RICHARD HUDSON, North Carolina       GENE GREEN, Texas
CHRIS COLLINS, New York              PETER WELCH, Vermont
KEVIN CRAMER, North Dakota           FRANK PALLONE, Jr., New Jersey (ex 
JOE BARTON, Texas                        officio)
FRED UPTON, Michigan (ex officio)

                                  (ii)
                                  
                                  
                                  
                                  
                                  
                                  
                                  
                                  
                                  
                                  
                                  
                                  
                                  
                                  
                                  
                                  
                                  
                                  
                                  
                                  
                             C O N T E N T S

                              ----------                              
                                                                   Page
Hon. Tim Murphy, a Representative in Congress from the 
  Commonwealth of Pennsylvania, opening statement................     1
    Prepared statement...........................................     3
Hon. Diana DeGette, a Representative in Congress from the State 
  of Colorado, opening statement.................................     4
Hon. Frank Pallone, Jr., a Representative in Congress from the 
  State of New Jersey, opening statement.........................     6
    Prepared statement...........................................     7

                               Witnesses

Jerome Adams, M.D., M.P.H., Commissioner, Indiana State 
  Department of Health...........................................     9
    Prepared statement...........................................    12
    Answers to submitted questions...............................    91
Monica Bharel, M.D., M.P.H., Commissioner, Massachusetts 
  Department of Public Health....................................    20
    Prepared statement...........................................    23
    Answers to submitted questions...............................    96
Larry Wolk, M.D., M.S.P.H., Executive Director and Chief Medical 
  Officer, Colorado Department of Public Health and Environment..    34
    Prepared statement...........................................    36
    Answers to submitted questions...............................   105
Mark Stringer, M.A., L.P.C., N.C.C., Director, Division of 
  Behavioral Health, Department of Mental Health, Missouri.......    40
    Prepared statement...........................................    42
    Answers to submitted questions...............................   111

                           Submitted Material

Subcommittee memorandum..........................................    71
Letter of May 21, 2015, from Don Flattery to Mr. Murphy and Ms. 
  DeGette, submitted by Ms. DeGette..............................    86

 
    WHAT ARE THE STATE GOVERNMENTS DOING TO COMBAT THE OPIOID ABUSE 
                               EPIDEMIC?

                              ----------                              


                         THURSDAY, MAY 21, 2015

                  House of Representatives,
      Subcommittee on Oversight and Investigations,
                          Committee on Energy and Commerce,
                                                    Washington, DC.
    The subcommittee met, pursuant to call, at 10:19 a.m., in 
room 2322 of the Rayburn House Office Building, Hon. Tim Murphy 
(chairman of the subcommittee) presiding.
    Members present: Representatives Murphy, McKinley, Burgess, 
Griffith, Bucshon, Flores, Brooks, Mullin, Hudson, Collins, 
Cramer, DeGette, Tonko, Clarke, Kennedy, Green, Welch, and 
Pallone (ex officio).
    Staff present: Will Batson, Legislative Clerk; Andy 
Duberstein, Deputy Press Secretary; Brittany Havens, Oversight 
Associate, Oversight and Investigations; Charles Ingebretson, 
Chief Counsel, Oversight and Investigations; Chris Santini, 
Policy Coordinator, Oversight and Investigations; Alan 
Slobodin, Deputy Chief Counsel, Oversight; Sam Spector, 
Counsel, Oversight; Christine Brennan, Democratic Press 
Secretary; Jeff Carroll, Democratic Staff Director; Christopher 
Knauer, Democratic Oversight Staff Director; Una Lee, 
Democratic Chief Oversight Counsel; Elizabeth Letter, 
Democratic Professional Staff Member; Adam Lowenstein, 
Democratic Policy Analyst; and Timothy Robinson, Democratic 
Chief Counsel.

   OPENING STATEMENT OF HON. TIM MURPHY, A REPRESENTATIVE IN 
         CONGRESS FROM THE COMMONWEALTH OF PENNSYLVANIA

    Mr. Murphy. Good morning. Today we convene the fourth in a 
series of hearings examining prescription drugs and heroin 
addiction, the growing nightmare of one of America's biggest 
public health crises.
    Since our opioid hearings earlier this month, approximately 
2,400 Americans have died from drug overdoses, and most of them 
because of opioid abuse. The size of this problem and the need 
for a new paradigm of treatment cannot be understated, and the 
process of developing legislative solutions has already 
started. Ranking Member DeGette and I have identified 15 areas 
in need of reform. One of those is 42 C.F.R. Part 2, which 
governs confidentiality protections for all substance use 
treatment records, both behavioral and physical, generated at a 
substance abuse treatment facility. It is well intended, but 
out dated, and Part 2 compromises medical care, increases the 
risk of dangerous and deadly adverse drug-to-drug interactions, 
and increases risk of relapse to addiction. My friend, 
Congressman Tonko from New York, and I have been working 
together to stop this medical records discrimination, and I 
thank him for his work.
    At the State level, responses to the epidemic vary. States 
like Indiana are responding to outbreaks of HIV and hepatitis. 
States on the east coast are confronting the problem of heroin 
laced with fentanyl, another narcotic pain reliever 100 times 
as powerful as morphine. Some States, mostly in the South, are 
burdened with the highest prescribing rates of opioid pain 
relievers, rates that are tenfold the rates in some other 
States. Also, State efforts share many similar challenges. The 
National Governors Association said States need accurate and 
timely information at their fingertips concerning the incidence 
and scope of the problem in order to develop an effective 
response. States have no choice but to use incomplete and 
outdated data to identify areas on which to concentrate their 
efforts, given their limited resources. Some States operate 
Prescription Drug Monitoring Programs, but these systems may 
not be easy to use. In Massachusetts, I believe it takes 
doctors 11 steps to use the program, which makes it difficult 
to encourage a high degree of participation. State systems are 
not necessarily connected to the systems of neighboring States, 
enabling abusers to doctor-shop across borders since their 
actions are not tracked. Further, the data on these systems can 
sometimes be several weeks old, escalating the risk for errors 
from inaccurate data.
    Overdose prevention remains a key aim of any meaningful 
State strategy, yet States have adopted different approaches to 
address it. Some provide liability protection for individuals 
who act in good faith to provide medical assistance to others 
in the event of an overdose, or expand access to the lifesaving 
drug naloxone, or use public education on the proper disposal 
of prescription drugs that are vulnerable to misuse.
    States also differ on availability and financing of 
medication-assisted treatments. Opioid maintenance is a bridge 
for those with addiction disorders to cross over in the 
recovery process, and we support that. Full recovery is 
complete abstinence. Medication-assisted treatment is valuable, 
but it must be coupled with proven psychosocial therapies and 
other wraparound services to support the person traversing this 
difficult road and to help with long-term, sustained recovery.
    Today we want to hear from the States about best-practice 
models, problems that they have encountered, and how States 
have addressed this problem. We also seek absolutely candid and 
honest input from each of our witnesses. Please tell us where 
there are problems, and please tell us where there are 
successes with any Federal programs or policies. We will hear 
from representatives of Indiana, Massachusetts, Missouri, and 
Colorado State Governments, a sampling of the 50-plus separate 
efforts being pursued by U.S. States and territories to counter 
opioid abuse. We are honored to have our witnesses join us this 
morning. We thank you for appearing today and look forward to 
hearing your testimony.
    [The prepared statement of Mr. Murphy follows:]


                 Prepared statement of Hon. Tim Murphy

    Today we convene the fourth in a series of hearings 
examining prescription drugs and heroin addiction; the growing 
nightmare of one of America's biggest public health crises. 
Since our opioid hearing earlier this month approximately 2,400 
Americans have died from drug overdoses, most of them because 
of opioid use.
    The size of this problem and the need for a new paradigm of 
treatment can't be understated. And, the process of developing 
legislative solutions has already started. Ranking Member 
DeGette and I have identified 15 areas in need of reform. One 
of those is 42 CFR Part 2, which governs confidentiality 
protections for all substance use treatment records, both 
behavioral and physical, generated at a substance abuse 
treatment facility. Well intended, but out dated, Part 2 
compromises medical care, increases the risk of dangerous and 
deadly adverse drug-to-drug interactions, and increases risk of 
relapse to addiction. Congressman Tonko from New York and I 
have been working together to stop this medical records 
discrimination. I thank him for his work.
    At the State level, responses to the epidemic vary. States 
like Indiana are responding to outbreaks of HIV and hepatitis. 
States on the east coast are confronting the problem of heroin 
laced with fentanyl, another narcotic pain reliever 100 times 
as powerful as morphine. Some States, mostly in the South, are 
burdened with the highest prescribing rates of opioid pain 
relievers, rates that are 10 fold the rates in some States.
    Also, State efforts share many similar challenges. The 
National Governors Association said States need accurate and 
timely information at their fingertips concerning the incidence 
and scope of the problem in order to develop an effective 
response. States have no choice but to use incomplete and 
outdated data to identify areas on which to concentrate their 
efforts given their limited resources.
    Some States operate Prescription Drug Monitoring Programs, 
but these systems may not be easy to use. In Massachusetts, it 
takes doctors 11 steps to use its program, which makes it 
difficult to encourage a high degree of participation. State 
systems are not necessarily connected to the systems of 
neighboring States, enabling abusers to doctor-shop across 
borders since their actions are not tracked. Further, the data 
on these systems can sometimes be several weeks old, escalating 
the risk for errors from inaccurate data.
    Overdose prevention remains a key aim of any meaningful 
State strategy, yet States have adopted different approaches to 
address it. Some provide liability protection for individuals 
who act in good faith to provide medical assistance to others 
in the event of an overdose or expand access to the life-saving 
drug naloxone or use public education on the proper disposal of 
prescription drugs that are vulnerable to misuse. States also 
differ on availability and financing of medication assisted 
treatments.
    Opioid maintenance is a bridge for those with addiction 
disorders to cross over in the recovery process. Full recovery 
is complete abstinence. Medication assisted treatment must be 
coupled with proven psycho-social therapies and other wrap-
around services to support the person traversing this difficult 
road and to help with long-term, sustained recovery.
    Today we want to hear from the States about best-practice 
models, problems they have encountered, and how States have 
addressed these problems. We also seek absolutely candid and 
honest input and ideas about where there are problems and 
successes with any Federal policies.
    We will hear from representatives of the Indiana, 
Massachusetts, Missouri, and Colorado State Governments, a 
sampling of the 50-plus separate efforts being pursued by U.S. 
States and territories to counter opioid abuse.
    We are honored to have our witnesses join us this morning. 
We thank you for appearing today and look forward to hearing 
your testimony.

    Mr. Murphy. And I am purposefully cutting this short so we 
can keep this moving.
    Ms. DeGette. OK.
    Mr. Murphy. I recognize Ms. DeGette for 5 minutes.


 OPENING STATEMENT OF HON. DIANA DEGETTE, A REPRESENTATIVE IN 
              CONGRESS FROM THE STATE OF COLORADO

    Ms. DeGette. Thank you very much, Mr. Chairman. I have been 
asking you to have a hearing so we can hear from the States, 
and I am glad that the States are here. I think it is important 
because much of the work in this area is happening in the 
States.
    I am particularly glad that Dr. Wolk is here from my home 
State of Colorado. I am eager to hear about what is happening 
in Colorado, particularly the positive developments in reducing 
prescribing rates and illicit use of opioid painkillers. It is 
clear that if we wish to reduce the problem of opioid 
dependency in our communities, we also have to address the 
issue of overprescribing. Last year, the CDC released a report 
on the correlation between opioid prescribing rates and drug 
overdose rates. CDC Director Tom Frieden stated, ``Overdose 
rates are higher when these drugs are prescribed more 
frequently. States and practices where prescribing rates are 
highest need to take a particularly hard look at ways to reduce 
the inappropriate prescription of these dangerous drugs.''
    Colorado has taken a number of important steps to address 
the opioid epidemic at its source. In September 2013, statewide 
leadership established the Colorado Consortium on Prescription 
Drug Abuse Prevention; its goal is to reduce the misuse of 
prescription drugs through physician training and education, 
public outreach, and safe disposal. The goal of the coalition 
is also to prevent 92,000 Coloradans from misusing opioids by 
2016, and I am sure we can get a good progress report on that 
from Dr. Wolk. I know that Colorado has seen the rate of non-
medical use of opioid painkillers fall already as a result of 
its work, and I am hoping we can hear about some of these best 
practices and lessons learned in this process.
    I am also eager to hear about how the other States here 
today are working to monitor prescribing rates, and reduce the 
number of opioid painkiller prescriptions. Experts tell us that 
the State Prescription Drug Monitoring Programs, or PDMPs, are 
an integral part of the solution to overprescribing. PDMPs can 
facilitate better clinical decision-making by prescribers, 
reduced doctor-shopping, and help physicians refer individuals 
for addiction treatment. I am interested to hear about the 
efforts that the States are undertaking to make PDMPs a more 
effective tool. For example, again, in Colorado, we were able 
to double our PDMP utilization rate from 41 percent to 84 
percent in just 1 year. Massachusetts also has high provider 
participation rates. I would like to know how we were able to 
achieve such great results in such a short time.
    Finally, I am interested to know more about the innovative 
efforts that States are undertaking on the treatment side of 
the equation. For instance, Missouri has made medication-
assisted treatment available through all its State behavioral 
health organizations. The State does not contract with 
organizations that do not provide MATs. This is an important 
step to ensure that patients have access to the full evidence-
based care that they need. Colorado is also taking steps to 
improve treatment for substance abuse disorders by integrating 
behavioral and primary care services in the State Medicaid 
Program. This is an ambitious goal of integrating 80 percent of 
the primary care practices with behavioral health services, 
including emergency departments, clinics, and private 
practices. I look forward to hearing more about this initiative 
and to similar efforts that are taking place in Massachusetts.
    So the States before us have made some impressive efforts 
to address this public health concern, but I want to caution 
that a lot more work needs to be done. Even before the opioid 
epidemic began, our infrastructure for treating substance abuse 
disorders in this country was remarkably inadequate to deal 
with the prevalence of the disease of addiction. Given the 
history of neglect and underinvestment in substance abuse, it 
is no wonder that the opioid epidemic resulted in a public 
health crisis.
    There is just one last thing I want to talk about, Mr. 
Chairman. We had a fellow show up just in the audience at our 
last hearing, Don Flattery, and Don came as a citizen because 
he lost his son, Kevin, to an opioid overdose last Labor Day, 
and when you hear about his son, Kevin, and when you hear about 
what this family went through, it is just heartbreaking. It is 
heartbreaking. I know all of our hearts go out to their family. 
They dedicated an immense amount of time and resources to 
getting the best treatment for Kevin, but they couldn't find 
access to the resources and quality treatment that they needed. 
I really want to thank Don for sharing his story with us, and 
for providing the committee with valuable insight into the 
problem. I am hoping we can hear from others like Don about the 
day-to-day challenges they face. Don wrote us a letter which 
talked about what has happened with his family, and I would ask 
unanimous consent to put that in the record, Mr. Chairman.
    [The letter appears at the conclusion of the hearing.]
    Mr. Murphy. Well, I agree, because I read the letter, too. 
It is powerful.
    Ms. DeGette. Yes. Thank you. And thanks again for holding 
this hearing, and I will yield back.
    Mr. Murphy. Yes, I just want to note too, I appreciate your 
request for doing this on a State level. I also want to 
acknowledge that I received a letter from you and Mr. Pallone 
on other suggestions for the committee. We do a lot of 
cooperative work together, and although that will never make 
the news that Members of Congress do work together on both 
sides of the aisle, I wanted to publically acknowledge my 
gratitude for you on that.
    Now, I don't know if there are any members on this side who 
want to make an opening statement, but I would like to give an 
opportunity to our colleagues from Indiana to introduce the 
witness from Indiana. Dr. Bucshon, are you going first or is 
Mrs. Brooks going first?
    Dr. Bucshon, you are recognized first.
    Mr. Bucshon. Thank you, Mr. Chairman. Today, I have the 
pleasure of introducing Indiana State Health Commissioner, Dr. 
Jerome Adams. Through extensive work as a researcher, as well 
as a policy leader, Dr. Adams brings a vast breadth of 
knowledge and experience to both the current opioid abuse 
epidemic in our State and to the witness panel. As we continue 
to work to curb the opioid abuse epidemic occurring through the 
country, parts of Indiana have recently seen HIV outbreaks as a 
direct result from this epidemic, presenting Dr. Adams with a 
unique challenge and a unique perspective on the current 
crisis. His expertise will undoubtedly be valuable to this 
committee.
    Dr. Adams, thank you for appearing before us today, and I 
look forward to your testimony.
    And I yield to Congresswoman Brooks from Indiana.
    Mrs. Brooks. Thank you, Dr. Bucshon.
    I want to thank the chairman for holding, once again, this 
important hearing, and to hear from witnesses who are battling 
this in our States. I want to extend a special welcome to Dr. 
Jerome Adams, my friend and constituent. It is wonderful for 
you to be here. And, in fact, his first day on the job, we were 
in an emergency meeting in Indianapolis focused on Ebola. And 
so here we are fast-forward just a few months, and I believe 
with your background not only as a physician from my medical 
school, but an anesthesiologist at Ball Memorial Hospital, that 
you do have the right kind of experience and background to help 
lead the State Health Department at this time. And as of May 
18, there have been 158 identified cases of HIV in Scott 
County, and that number has gone up from the time we last had a 
hearing, and we are asking the CDC about Scott County. And so 
we know that you and your team, many of whom are with you 
today, have done an amazing job of curbing the HIV epidemic and 
slowing its growth, and we look forward to hearing your 
testimony today.
    Thank you for being here.
    Mr. Murphy. Gentleman----
    Mr. Bucshon. Yield back.
    Mr. Murphy [continuing]. Yields back? All right, I 
recognize Mr. Pallone for 5 minutes.

OPENING STATEMENT OF HON. FRANK PALLONE, JR., A REPRESENTATIVE 
            IN CONGRESS FROM THE STATE OF NEW JERSEY

    Mr. Pallone. Thank you, Mr. Chairman. And I want to thank 
you and Ms. DeGette for the hearing, and for your due diligence 
in investigating the opioid abuse epidemic. I am glad the 
subcommittee is devoting significant attention to this issue 
because like all of the members here today, I am concerned 
about what is happening in my State.
    A New Jersey State official recently reported that more 
than 6,000 people in New Jersey have died from overdoses since 
2004. He also reported that more teens are dying from drug 
overdoses in New Jersey than car accidents. Today, we are 
hearing from State health officials about ongoing efforts 
within their agencies to combat this epidemic. And I know you 
all are dealing with many aspects of this issue, from reducing 
opiate prescribing rates, to increasing access to treatment to 
programs, and I look forward to hearing about the work you are 
doing, and I hope we can all learn from each other.
    I also want to hear from all the witnesses today about how 
we as the Federal Government can help fight this epidemic. We 
heard earlier this month from a number of Federal agencies 
about their work, but I want to make sure we are supporting the 
States and their efforts to address the epidemic.
    We have heard repeatedly throughout this series of hearings 
that significant barriers to treatment for substance use 
disorders still exist. For example, SAMHSA's 2013 National 
Survey on Drug Abuse and Health found that nearly 40 percent of 
individuals who make an effort to seek treatment were unable to 
get treatment due to lack of health coverage and the 
prohibitive cost of treatment. Another 8 percent reported that 
they had health coverage but it did not cover the cost of 
treatment. And with the passage of the Affordable Care Act, 
approximately 16.4 million Americans have gained health 
insurance coverage, and insurance companies are now required to 
provide treatment for substance abuse disorders and coverage, 
just as they would cover treatment for any other chronic 
disease. But we still need to understand where barriers to 
treatment remain, and we should work on making sure those who 
want to access treatment are able to do so.
    I also want to hear from all of our witnesses today about 
how Medicaid expansion, or in Missouri's case of failure to 
expand Medicaid, has had an impact on treatment for substance 
abuse disorders. I know Massachusetts and Colorado both signed 
Medicaid expansions into law in 2013, and Indiana expanded 
Medicaid earlier this year, so I am interested to hear from all 
three of your States about how Medicaid expansion has improved 
access to behavioral health services, and I want to hear from 
Missouri how Medicaid expansion could help those seeking access 
to behavioral health services and what challenges you face by 
not expanding the program. So thanks again.
    [The prepared statement of Mr. Pallone follows:]

             Prepared statement of Hon. Frank Pallone, Jr.

    Mr. Chairman, thank you for holding today's hearing and for 
your due diligence in investigating the opioid abuse epidemic. 
I'm glad this subcommittee is devoting significant attention to 
this issue because like all of the Members here today, I am 
concerned about what is happening in my State.
    A New Jersey State official recently reported that more 
than 6,000 people in the State have died from overdoses since 
2004. He also reported that more teens are dying from drug 
overdoses in New Jersey than car accidents.
    Today, we are hearing from State health officials about 
ongoing efforts within their agencies to combat this epidemic. 
I know you all are dealing with many aspects of this issue, 
from reducing opioid prescribing rates to increasing access to 
treatment to programs.
    I look forward to hearing about the work you are doing, and 
I hope you all can learn from each other as well.
    I also want to hear from all of the witnesses today how we 
as the Federal Government can help fight this epidemic. We 
heard earlier this month from a number of Federal agencies 
about their work, but I want to make sure we are supporting the 
States in their efforts to address the epidemic.
    We have heard repeatedly throughout this series of hearings 
that significant barriers to treatment for substance use 
disorders still exist. For example, SAMHSA's 2013 National 
Survey on Drug Use and Health found that nearly 40% of 
individuals who made an effort to seek treatment were unable to 
get treatment due to lack of health coverage and the 
prohibitive cost of treatment. Another 8% reported that they 
had health coverage, but it did not cover the costs of 
treatment.
    With the passage of the Affordable Care Act, approximately 
16.4 million Americans have gained health insurance coverage. 
And insurance companies are now required to provide treatment 
for substance abuse disorders and cover it just as they would 
cover treatment for any other chronic disease.
    But we still need to understand where barriers to treatment 
remain, and we should work on making sure those who want to 
access treatment are able to do so.
    I also want to hear from all of our witnesses today about 
how Medicaid expansion--or in Missouri's case, a failure to 
expand Medicaid--has had an impact on treatment for substance 
abuse disorders. I know Massachusetts and Colorado both signed 
Medicaid expansion into law in 2013, and Indiana expanded 
Medicaid earlier this year.
    I'm interested to hear from all three of your States about 
how Medicaid expansion has improved access to behavioral health 
services. And I want to hear from Missouri how Medicaid 
expansion could help those seeking access to behavioral health 
services and what challenges you face by not expanding the 
program.
    Thank you again for holding this hearing, and thank you to 
all our witnesses for sharing your insight today.
    I yield my remaining time to Rep. Kennedy.

    Mr. Pallone. I would like now to yield the rest of my time 
to Representative Kennedy.
    Mr. Kennedy. Thank you. I would like to thank the ranking 
member. I would also like to thank the chairman of the 
committee for calling this extraordinary series of hearings. 
They have been, I think, extremely enlightening, and shining a 
light on an incredible epidemic our country is facing.
    To the witnesses today, thank you so much for being here to 
discuss the States' efforts to combat opioid abuse. In my mind, 
we are here for one reason; to learn from you about what has 
worked on the ground in your States, and how we can try to 
support those efforts at a Federal level in any way possible.
    Few in my home State have been spared the tragic 
consequences of the ongoing opioid epidemic. Last year, there 
were more than 1,000 deaths in our Commonwealth, spanning 
wealthy and low-income communities alike, areas rural and 
urban, faces young and old.
    Dr. Bharel has been on the frontlines of this battle for 
long before she was appointed to the Public Health Commission 
earlier this year, but in her new role, she is focused on 
ensuring treatment options are available to all of our 
citizens, regardless of income. It is my honor to welcome her 
today to Washington, and I look forward to hearing your 
testimony.
    One issue I hope to hear from all of you today is a little 
bit about one of the issues we have been wrestling with in 
Massachusetts, which is the rising cost of Narcan. At a time 
when our country needs every tool at its disposal in this 
fight, the price of lifesaving treatment continues to 
skyrocket. Last month in Needham, Massachusetts, the cost per 
dose rose to $66.89, up from $19.56 last June.
    Now, Narcan is by no means an answer to this epidemic. It 
is a stopgap, not a solution, but it does save lives. It allows 
us to get individuals suffering from crippling addiction into 
treatment. It helps minimize the number of parents, brothers, 
sisters, and children with loved ones who are taken far too 
soon. So I would be interested to hear from our witnesses about 
any price spikes that you have seen at home, how those have 
impacted response efforts, and how the Federal Government can 
help ensure that no one's life is lost because a municipality 
simply can't afford a drug.
    Another area that I would like to get some insight on is 
the effectiveness of Prescription Drug Monitoring Programs. I 
represent a district in Massachusetts that borders Rhode 
Island, and it has become clear to me that the lack of 
communication across State lines is leaving a gap in how we 
tackle prescription drugs. To that end, I helped to cosponsor 
the National All Schedules Prescription Electronic Reporting 
Act with Congressman Whitfield in an effort to better support 
State PDMPs, particularly where interoperability is concerned. 
Drs. Adams, Bharel, Wolk, I hope you will expand a little bit 
more on the roles PDMPs have played in your States' efforts 
today. Dr. Stringer, I would love if you would be able to touch 
a little bit about your State's plans to develop a PDMP.
    Tackling an epidemic of this scope requires partners across 
local, State, and Federal levels. To that end, we are all 
deeply grateful for your presence here today, and look forward 
to supporting you any way we can.
    Thank you, and I yield back.
    Mr. Murphy. Gentleman yields back.
    I would now like to introduce the witnesses on the panel 
for today's hearing. We have already heard about Dr. Jerome 
Adams, the Health Commissioner of the Indiana State Department 
of Health. Welcome. Dr. Monica Bharel, the Commissioner of the 
Massachusetts Department of Health. Dr. Larry Wolk, the 
Executive Director and Chief Medical Officer at the Colorado 
Department of Public Health and Environment. And Mr. Mark 
Stringer, the Director of the Division of Behavioral Health at 
the Missouri Department of Mental Health.
    I would now like to swear in the witnesses.
    You are all aware that the committee is holding an 
investigative hearing, and when doing so, has the practice of 
taking testimony under oath. Do any of you have any objections 
to testifying under oath? All the witnesses answered negative. 
The Chair then advises you that under the rules of the House 
and the rules of the committee, you are entitled to be advised 
by counsel. Do any of you desire to be advised by counsel 
today? All the witnesses indicate no. In that case, if you will 
all please rise and raise your right hand, I will swear you in.
    [Witnesses sworn.]
    Mr. Murphy. You are now under oath and subject to the 
penalties set forth in Title XVIII, Section 1001 of the United 
States Code. You may now each give a 5-minute summary of your 
written statement, and please try to be under 5 minutes. You 
will need to press the button so the green light is on, and 
pull the microphone fairly close to you. Thank you.
    Dr. Adams, you are recognized for 5 minutes.

STATEMENTS OF JEROME ADAMS, M.D., M.P.H., COMMISSIONER, INDIANA 
   STATE DEPARTMENT OF HEALTH; MONICA BHAREL, M.D., M.P.H., 
COMMISSIONER, MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH; LARRY 
  WOLK, M.D., M.S.P.H., EXECUTIVE DIRECTOR AND CHIEF MEDICAL 
OFFICER, COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT; 
AND MARK STRINGER, M.A., L.P.C., N.C.C., DIRECTOR, DIVISION OF 
    BEHAVIORAL HEALTH, DEPARTMENT OF MENTAL HEALTH, MISSOURI

                   STATEMENT OF JEROME ADAMS

    Dr. Adams. Thank you very much. My name is Jerome Adams. I 
am the Indiana State Health Commissioner, I am a physician 
anesthesiologist, and I am the brother of an addict. On behalf 
of Governor Mike Pence and the people of Indiana, it is my 
honor to be here today.
    In rural Scott County, we are dealing with the largest 
injection-drug-use-related HIV outbreak in decades, with what 
CDC Director Tom Frieden described as a higher incidence of HIV 
than any country in sub-Saharan Africa. In an area that had 
three total cases of HIV over the prior 4 years, we, as of 
today, have 160 positives, with 95 percent related to injection 
drug use, and Hepatitis C co-infection rate of 88 percent.
    At the root of this outbreak is our country's prescription 
opioid crisis. The crisis is multifactorial, but I think it is 
helpful to separate it into three distinct problem and solution 
areas. Number one, we need to stop the flow of opioids into 
communities. Number two, we need to deal with the personal and 
public health consequences of communities with overflow of both 
opioids and people engaging in high-risk activities. And number 
three, we need to create an outlet for those seeking recovery 
from substance use disorder.
    In terms of stopping the flow, in Indiana we witnessed a 10 
percent decrease in prescriptions since we implemented new 
opioid prescribing rules in 2012, but we still have work to do. 
We need an aggressive education and prevention strategy 
starting in childhood. In addition to promoting the dangers of 
prescription drug misuse, we need better Prescription Drug 
Monitoring Programs with required reporting from the VA and 
Federal methadone treatment centers, higher thresholds for new 
FDA approvals of opioids, and safety and efficacy reviews of 
previously approved opioids based on recent data. Policies 
should further promote pharmacy and community opioid take-back 
programs, and require opioid manufacturers to facilitate these 
endeavors. And we should revisit both pain as the fifth vital 
sign, and the pain component of patient satisfaction as a 
consideration for physician and hospital reimbursement. Our 
focus needs to be on functionality and outcomes, and not simply 
on stopping pain with pills.
    Regarding the consequences of opioid overflow, we have seen 
not just an HIV epidemic, but also regional epidemics of 
Hepatitis, overdose deaths, unsustainable levels of 
incarceration, and community hopelessness. Our comprehensive 
approach in Scott County includes increased HIV and Hepatitis 
testing, and immediate treatment referral, locally based harm 
reduction strategies, immunizations, healthcare coverage, job 
training, and an outreach campaign targeting drug users and 
those involved in the commercial sex trade.
    On a State level, we have formed a Neonatal Abstinence 
Syndrome Committee, and recently made Naloxone available for 
first responders and friends or family members of those at 
risk. As Governor Pence said when he signed our Naloxone Bill, 
bills like this are about saving lives. Thanks to Governor 
Pence fighting hard to receive the only Federal waiver of its 
kind, and to Representative Pallone's point, we can further 
address the needs of those with substance use disorder, 
including healthcare coverage and access, the two are not 
equal, and job training via our Healthy Indiana Plan. If people 
don't have hope, they will increasingly turn to and stay on 
drugs; a painful lesson we have learned from Scott County. 
Fortunately, over 225,000 Hoosiers have more hope now thanks to 
HIP 2.0.
    Lastly, in terms of creating an outlet, we must provide 
options for those seeking recovery services. A national 
campaign could reduce the stigma of substance use disorder and 
HIV so people aren't ashamed to seek services, and could help 
reframe addiction from that of a moral failure to that of a 
medical disorder that requires a lifetime of attention. Lack of 
recovery reflects a lack of enlightenment on society's part, as 
much of it reflects a lack of earnestness on the sufferer's 
part.
    Regarding recovery in Scott County, we have found a severe 
and unmet need for access to appropriate substance use disorder 
treatment, and we have accordingly worked to increase beds in 
outpatient services. When incarcerated, sufferers also should 
have access to mental health and addiction treatment, with 
linkages to these services upon release. Such programs exist in 
Indiana, but are often only found in the most well-resourced 
communities. And we must educate communities and the public 
about medication-assisted treatment as an important component 
of the recovery safety net. Recently enacted legislation in 
Indiana allows the establishment of additional methadone 
clinics in our State, and the criminal justice system at the 
county level is increasingly offering Vivitrol for inmates upon 
release, or as an option during drug court diversion programs.
    Our situation in Indiana, in closing, may be unprecedented 
in many ways, but in many others, it illustrates problems faced 
throughout our country. There is much we do, but I am confident 
that we can succeed. If we focus on education, patient-centered 
care, and community and patient empowerment, I am confident we 
can successfully combat the scourge of opioid abuse.
    Mr. Chairman, thank you for your time, and I look forward 
to the opportunity to answer your questions.
    [The prepared statement of Dr. Adams follows:]
    
    
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    Mr. Murphy. Thank you very much, Doctor.
    And now, Dr. Bharel, you are recognized for 5 minutes.

                   STATEMENT OF MONICA BHAREL

    Dr. Bharel. Thank you, Chairman Murphy, Ranking Member 
DeGette, and the members of the committee. Thank you for 
welcoming us here today, and for the opportunity to provide 
this testimony on this incredibly pressing issue today.
    My name is Dr. Monica Bharel, and I am proud to have been 
appointed to serve the Commonwealth of Massachusetts and 
Governor Baker as its Commissioner of Public Health. I am 
honored to be here representing one of the Nation's oldest 
public health departments; one that traces its roots back to 
Commissioner Paul Revere, and one that has continually led the 
way in public health across the country. Yes, we can talk more 
about that later.
    As a----
    Mr. Murphy. He alerted people with lanterns, I am aware of 
that. So----
    Dr. Bharel. He gave out information on cholera throughout 
the Commonwealth.
    As a frontline physician and as a former Chief Medical 
Officer at Boston Healthcare for the Homeless Program, the 
largest of its kind in the Nation, I have seen firsthand the 
rising tide of an opioid epidemic that is overwhelming 
communities. We have watched our family and friends die on our 
streets, driven by a lethal cocktail of trauma and underlying 
behavioral health issues. This is not something we as a society 
should accept as the norm.
    This epidemic will be far from easy to tackle, but this 
challenge is precisely what drew me here to work with you and 
our providers, our community leaders.
    To that end, we are already hard at work in Massachusetts 
and throughout the Baker administration, redoubling our efforts 
to identify, triage, address, and treat the opioid epidemic.
    First, to identify the problem. Like so many States across 
the Nation, Massachusetts is facing a growing epidemic of 
opioid addiction and overdose deaths. In 2013, there were 967 
unintentional opioid deaths, compared to 371 motor-vehicle-
related injury deaths. That is 2 \1/2\ times as many people 
dying from opioid use as for motor-vehicle-related injuries. 
And behind those 967 deaths are over 2,000 hospital stays and 
more than 4,500 emergency room visits, and of course, 
unquantifiable human suffering. And in 2014, we have projected 
estimations of over 1,000 people dying of an opioid-related 
overdose. This is a 51 percent increase from 2012. We will fail 
in our efforts to address this crisis if we do not fully 
involve partners from all sectors. That includes law 
enforcement, public health, healthcare institutions, families, 
schools, and you, our elected officials.
    Governor Baker prioritized the opioid epidemic early in his 
new administration. In February, Governor Baker appointed 18 
individuals to serve on his Opioid Working Group. The group 
represents the many different perspectives that are important 
to this work, and was charged with developing tangible 
recommendations. The working group has held listening sessions 
across the Commonwealth, hearing from over 1,100 individuals, 
and receiving hundreds of recommendations and emails. No matter 
which of the lens these individuals look at this epidemic, one 
thing is obvious, that opioids are impacting every city and 
town in the Commonwealth. People speak again and again about 
the wish to have early prevention and increased access to 
treatment.
    Our success getting to the underlying health issues and 
social determinants that are driving this epidemic; trauma, and 
undiagnosed behavioral health issues are chief among those, 
will directly correlate with our ability to successfully 
leverage data and to measure results. This data will allow us 
over time to effectively target key populations and hotspot, if 
you will, to better understand the impact of our collective 
efforts, and how to use our limited resources better. 
Utilization of data to combat the opioid crisis has a long way 
to go. For example, currently in our Department of Public 
Health we have more than 300 different internal data systems 
that have developed by individual programs and use a variety of 
different formats. They are managed by different staff, and 
reside on different servers that don't talk to each other. 
However, this problem is not unique to Massachusetts, and 
across the country, public health needs to double down on data 
and on interoperable secure IT solutions, such as data 
warehousing, to create better linkages between our siloed data 
sets.
    As a frontline clinician, I have experienced firsthand the 
real roadblocks to helping patients access care. In the area of 
access, particularly with regards to downstream post-detox 
care, individuals have had a lot of trouble with both 
residential and outpatient medication treatment service 
availability. In capacity, statewide bed capacity, the kinds of 
bed types available and how to access them are not well known. 
Services for mothers and fathers in recovery who are attempting 
to reclaim their lives, while trying to take care of their 
children, needs improvement. Individuals suffering from 
addiction need better access to childcare, stable housing, and 
employment opportunities, as well as access to timely 
treatment. We need more early interventions in schools, and 
perhaps most important, this issue of stigma.
    What this hearing alone represents is an important step 
towards societal recovery. We need to talk about this disease. 
This is a chronic disease, and as a community and a nation, we 
will treat it and we will find pathways to recovery together by 
first speaking of it as a chronic disease. From the bedsides to 
the halls of bureaucracy, addressing this opioid crisis 
requires taking action across the spectrum of prevention, 
intervention, treatment, and recovery support. At DPH, we are 
proud of the progress we have made in areas such as access to 
Naloxone kits, with the cities of Quincy and Gloucester being 
some of the first communities in the Nation to arm themselves 
with Naloxone. Beyond saving lives, this measure has changed 
attitudes with police no longer arresting their way out of this 
epidemic, but looking towards solutions.
    Mr. Murphy. I will need you to wrap up, if you could.
    Dr. Bharel. Sure. And as a medical community, we know that 
20 percent of pain relievers for nonmedical use are coming 
directly from clinicians, so we as clinicians must shift our 
expectations of practices that opioids are not the first line 
of defense. However, as our national data sets demonstrate, 
more than 80 percent of lethal painkillers come from non-
clinicians. And so, again, this highlights the element of truth 
of working across partnerships.
    And I look forward to answering any further questions you 
have. Thank you.
    [The prepared statement of Dr. Bharel follows:]
    
    
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    Mr. Murphy. Thank you very much.
    Dr. Wolk, recognized for 5 minutes.

                    STATEMENT OF LARRY WOLK

    Dr. Wolk. Thank you, Chairman Murphy, Ranking Member 
DeGette, and members of the subcommittee for the opportunity to 
provide testimony to you today about our efforts to address the 
opioid epidemic in Colorado.
    In 2012, we had the troubling distinction of ranking second 
nationally for self-reported, nonmedical use of prescription 
drugs. More than \1/4\ million Coloradans misused prescription 
drugs, and consequent deaths related to misuse nearly 
quadrupled between 2000 and 2011. Drug overdose remains the 
leading cause of injury death in Colorado, and almost 11 
percent of Coloradans aged 18 to 25 still engage in nonmedical 
use of prescription drugs. In the last 5 years, the number of 
heroin users in Colorado has also doubled, and we are 
challenged with concerns that existing treatment capacity is 
not meeting a rising demand, as treatment admissions for heroin 
and prescription opioid abuse increased 128 percent between 
2007 and 2014. However, recent data suggests that we are 
heading in a better direction. 2013 data released shows that 
our rate on nonmedical use has decreased from 6 percent to 
nearly 5 percent, which represents 39,000 fewer Coloradans who 
misused prescription drugs. Additionally, the Colorado youth 
use rate is decreasing and is now below the national average. 
Since 2012, catalyzed by Governor Hickenlooper's leadership as 
the co-chair of the NGA's Policy Academy for reducing 
prescription drug abuse, we are currently implementing a 
coordinated approach, setting as our goal to prevent 92,000 
Coloradans from engaging in nonmedical use of prescription pain 
medications through the adoption of our Colorado plan to reduce 
prescription drug abuse. This commitment represents a reduction 
from 6 percent to 3 \1/2\ percent of Coloradans who self-report 
nonmedical use of prescription drugs, focusing on seven key 
areas: improved surveillance of prescription drug misuse data; 
strengthening the Colorado PDMP; educating prescribers and 
providers; increasing safe disposal; increasing public 
awareness; enhancing access to evidence-based effective 
treatment; and expanding access to the overdose reversal drug, 
Naloxone.
    To monitor and coordinate progress, State-level leadership 
created the Colorado Consortium for Prescription Drug Abuse 
Prevention. The consortium provides a statewide, interagency, 
interuniversity framework designed to facilitate the 
collaboration and implementation of the strategic plan, and is 
comprised of seven work groups. For one, the Data and Research 
Work Group of the consortium has worked to map out all sources 
of data related to prescription drug use, misuse, and overdose 
in the State. Second, the PDMP Work Group has worked over the 
past 2 years to enhance our State's PDMP as an effective public 
health tool. As of July 2014, our PDMP utilization rate was 41 
percent, and in April 2015, that rate more than doubled, 
reaching 85 percent. How did we accomplish this dramatic 
improvement? We recently implemented push notices to both 
prescribers and pharmacists when patients visit a certain 
number of prescribers and pharmacies to obtain a controlled 
substance. We require PDMP registration for pharmacists and 
DEA-registered prescribers, but we allow prescribers and 
pharmacists to assign and register delegates in their office, 
because they are often busy, so that those delegates can check 
the PDMP. We have also enhanced the PDMP interface and moved to 
a daily upload of data so that it is constantly refreshed. The 
Provider Education Work Group focuses on issues related to 
improving the education and training of healthcare 
professionals through a jointly developed policy; a policy that 
has since been adopted by the dental, medical, nursing, 
pharmacy, optometry, and podiatry Boards in Colorado. It is the 
first joint policy of its type adopted by multiple regulatory 
Boards. As of October 2014, over 1,300 prescribers had 
completed the training developed from this policy, and 87 
percent indicated that they intended to change their practice 
as a result. We were encouraged because the CDC morbidity and 
mortality report recently ranked Colorado 40th nationally for 
prescribing rates of opioids, fiftieth being the lowest rate of 
prescribing.
    The Safe Disposal Work Group focuses on issues relating to 
safe storage and disposal of prescription medications, with the 
potential for misuse, abuse, or diversion, knowing that more 
than 70 percent of those who abuse obtain them from the unused 
supplies of family and friends. This work group developed 
guidelines and outreach efforts, and expanded the number of 
safe disposal sites throughout the State. By next year, we have 
plans to provide drop boxes in every county in the State.
    Public Awareness Group has developed a new statewide 
advertising and public outreach campaign called Take Meds 
Seriously. Our consortium's Treatment Work Group has focused on 
identifying gaps in the need for medication-assisted treatment. 
And our Naloxone Work Group focuses on increasing awareness of 
and access to Naloxone, making clinical, organizational, and 
public policy recommendations to achieve this goal.
    I thank you for the opportunity. I see that I am out of 
time, and thank you.
    [The prepared statement of Dr. Wolk follows:]
    
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    Mr. Murphy. Thank you, Dr. Wolk.
    Mr. Stringer, you are recognized for 5 minutes.

                   STATEMENT OF MARK STRINGER

    Mr. Stringer. Chairman Murphy, Ranking Member DeGette, and 
members of the subcommittee, my name is Mark Stringer and I am 
the Director of the Division of Behavioral Health in the 
Missouri Department of Mental Health. I also have the privilege 
of serving as President of the Board of the National 
Association of State Alcohol and Drug Abuse Directors, or 
NASADAD. It is truly an honor to offer remarks this morning 
about what Missouri is doing regarding the opioid problem in 
particular, and addiction in general.
    If there is a theme running through our messages this 
morning, I believe one of the most important ones is that 
access to treatment and recovery services is essential to 
addressing this problem.
    On this very day in Missouri, nearly 3,000 people are on 
waiting lists for substance use disorder treatment services. 
That equates to about 43,000 Missourians waiting for help 
during the course of a year. What is truly sad about this is 
that often a person seeks treatment after some kind of a life-
altering event, a run-in with the law, a problem at work, some 
type of illness, an overdose. So every name on a waiting list 
is a potential tragedy for an individual, a family, and a 
community. In order to be successful, services must be 
accessible. They have to be individually tailored, evidence-
based, and they must include recovery supports. One thing I 
know with certainty after 30 years in this field is that 
treatment cannot be effective and treatment cannot possibly 
work if you can't get access to it when you need it.
    So I will give you some just quick information about my 
State of Missouri. We estimate that about 400,000 Missourians 
have substance use disorders. Last year, 43,000 actually 
received treatment services through the publicly funded system. 
With regard to opioids, Missouri saw 124 percent increase in 
treatment admissions related to prescription drugs from 2007 to 
2012, and 125 percent increase in admissions related to heroin. 
We lose about 200 people to heroin deaths each year; most of 
them in eastern Missouri, including St. Louis.
    Here are some steps we are taking to deal with the problem. 
We developed a statewide plan for coordinated treatment and 
recovery services, and we partner with providers to ensure that 
services are high quality and evidence-based. One tool for 
promoting quality is our contracting authority; building in 
certain requirements that providers must follow as a condition 
of receiving State funds. We perform on-site certification 
reviews to assure that providers are adhering to standards of 
care that are set by the State. As an example, we use these 
tools to require that all addiction treatment providers in 
Missouri who are, again, contracted with the State make 
medication-assisted treatment available, either directly or by 
referral. This took time, resources, and education, and it is a 
work in progress but it is the right step for Missouri. We have 
also worked hard to leverage SAMHSA's Access To Recovery 
program, or ATR, to build a statewide system of recovery 
services. Prevention is critical. Our State has a strategic 
plan for prevention, with a focus on prescription drug abuse. 
And we have partnered with a group, just as an example, in a 
college setting we have a group called Partners in Prevention, 
that is a coalition of 21 college campuses located throughout 
Missouri, which is working specifically on prescription drug 
abuse among college students. This effort has made a 
difference. From 2013 to 2014, we have seen a 10 percent 
decrease in the misuse of prescription drugs among college 
students.
    There are other initiatives in my written testimony, but I 
will now turn to a few recommendations. I recommend that all 
Federal initiatives specifically include involvement of State 
substance abuse agencies, like mine. Given their expertise and 
authority over the addiction prevention, treatment and recovery 
systems. And I particularly want to recognize the Director of 
the Office of National Drug Control Policy, Michael Botticelli, 
for his efforts to coordinate drug policy across Federal 
Government, and to keep States informed and engaged.
    Second, I recommend strong support for the Substance Abuse 
Prevention and Treatment Block Grant, a vital part of the 
public safety net for treatment that also provides an average 
of 70 percent of State substance abuse agencies' funding for 
primary prevention.
    Third, I support specific initiatives to increase the 
availability of all FDA-approved medications for substance use 
disorders, and I applaud the administration's proposed $25 
million for States to expand opioid treatment services where 
medication-assisted treatment is an allowable use of funding.
    Fourth, I recommend specific resources to help States and 
localities purchase Naloxone. This would have an immediate 
lifesaving impact, and I appreciate the administration's 
proposal to provide $12 million within SAMHSA for overdose 
reversal and prevention activities. I certainly support 
mandatory prescriber education and training on substance use 
disorders. And finally, I encourage Congress and the 
administration to continue to work with State-based groups 
heavily involved in this issue, including groups like the 
National Association of State Alcohol and Drug Abuse Directors, 
the Association of State and Territorial Health Officers, but 
also our parent group, the National Governors Association, 
which has provided critical leadership in this area.
    Thank you for the opportunity to testify, and I look 
forward to answering questions.
    [The prepared statement of Mr. Stringer follows:]
    
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    Mr. Murphy. I thank all the panelists.
    I will now recognize myself for 5 minutes of questions.
    Mr. Stringer, your office sits within Missouri's Department 
of Mental Health, and in the course of your work, have you 
found that Federal policies, including those affecting the ways 
in which certain treatment options are funded, have hampered 
any mechanism to treat individuals with co-occurring substance 
abuse and mental health disorders, and if so, what can be done, 
what do you suggest we do to correct that?
    Mr. Stringer. Mr. Chairman, I am not sure it is a policy 
issue. I am going to try to answer that yes or no. Yes. Yes, 
there are some things that get in the way of treating people 
with co-occurring disorders. Primarily has to do with funding 
screens, how funding comes to the States, what the limitations 
are, and how those funds are spent.
    We have been successful in Missouri, I think, at braiding 
funds for people with co-occurring disorders, and so we treat 
some--so what we have done is really enhance our substance use 
disorder programs to include some mental health services. We 
have enhanced our community mental health services to include 
substance use disorder services. So we have been able to do 
that with the flexibility that is already there.
    Mr. Murphy. I asked that because we have had other 
witnesses say they would like to let the Federal Government 
merge some of those funds so they can treat both.
    I would like to open this question up to all of you. I made 
some comments in my opening statement regarding the 42 C.F.R., 
and some concerns it has with interfering with doctors' ability 
to provide safe and effective treatment for patients. I don't 
know if any of you have reports from the State, but let me 
elaborate on this. A basic quality measure of good healthcare 
is medication reconciliation, as you are aware, which means 
assessing and documenting all the medications someone may be 
taking, which would include buprenorphine, Vivitrol, or all 
these other ones, but as a result of the 42 C.F.R. Part 2, a 
doctor's ability to complete these medication reconciliations 
is very compromised. As I said, Mr. Tonko and I are working on 
this, so a patient may be getting Suboxone from an addiction 
medication physician, but this person may fail to inform their 
family physician, who may recommend another thing, or you can 
have someone on Vivitrol and--doesn't tell a physician, and 
next thing you know, they get a pain medication, an opiate, and 
now you have someone who either has a risk of death, or you 
increase their risk for relapse. And I wonder if any of you can 
comment. Do you have any suggestions on this? Dr. Wolk, you are 
nodding your head. You have some comments on that?
    Dr. Wolk. Thank you, Mr. Chair. Prior to assuming this role 
2 years ago, I was the CEO for the State's Health Information 
Exchange, CORHIO. And you highlight a very big obstacle when it 
comes to exchanging and making available clinical information 
to all providers involved in a patient's care. If the health 
information exchange is going to work with regard to reducing 
duplication, improving quality, and reducing cost, the 
healthcare provider has to have access to all of the patient's 
information, whether it is physical, mental health, or 
substance abuse-related. So----
    Mr. Murphy. And we do have barriers that mental health 
therapy notes don't get into those things, which is--OK. That 
is a good point.
    I want to follow up with one. Dr. Adams, I want to catch 
you before my time is out here. The diversion of buprenorphine 
for illicit nonmedical use is a significant problem, and that 
is just a part of the reason why the opioid epidemic is 
spreading. According to the Drug Enforcement Administration, 
buprenorphine is the third most seized prescription opiate by 
law enforcement. And so is the diversion of buprenorphine a 
significant problem in your State, and how are you handling 
that?
    Dr. Adams. It is a significant problem in parts of our 
State, and that is why we need to have a larger conversation 
about medication-assisted treatment and what it can and cannot 
do. Vivitrol, for instance, is a wonderful drug for a very 
small subset of the population. Methadone, we need to separate 
the discussion between methadone for chronic pain versus 
methadone for substance abuse treatment in medication-assisted 
therapy. And so again, I would promote educational campaigns 
both for the public, for policymakers, and for physicians, 
quite frankly, in terms of what can and can't be accomplished. 
And Suboxone is a great drug, again, for a certain subset of 
the population, when done right, but we have found when done 
wrong, diversion can occur, and that is a concern that has been 
brought up by particularly our correctional facilities where 
people say they can easily sneak it in to the correctional 
facilities.
    Mr. Murphy. I appreciate that. And my time is almost up, 
but this is the kind of thing we are going to want you to 
comment on. In addition, we made reference before to Don 
Flattery's letter to us, and he brings up an important point 
here that opiate pain relievers, or OPRs, can worsen chronic 
pain over time. And that is another area, it seems to me, as 
you are recommending we need to do much more in education--
mandatory education of physicians and prescribers on that. So 
keep that thought in mind, we are going to want some input on 
that too.
    I now recognize----
    Dr. Adams. Mr. Chairman, one thing you can do concretely is 
you can have the VA and you can have Federal methadone programs 
report to Prescription Drug Monitoring Programs. You all can do 
that, and that will help get information out to the physicians.
    Mr. Murphy. Excellent, thank you. Thank you.
    Ms. DeGette, 5 minutes.
    Ms. DeGette. Well, thank you. This sort of follows up on 
your line of questioning, Mr. Chairman.
    Dr. Wolk, I wanted to talk to you about the Prescription 
Drug Monitoring Program a little bit, and what we have done in 
Colorado, we passed a law in Colorado that now requires medical 
professionals who prescribe powerful controlled substances to 
sign up for an account. Is that right, Dr. Wolk?
    Dr. Wolk. Thank you, Representative DeGette. That is 
correct.
    Ms. DeGette. And since Colorado implemented that law, the 
use rate of the PDMP has doubled, going from about 40 to 85 
percent in less than a year. Is that right?
    Dr. Wolk. Thank you, Representative DeGette. That is also 
correct.
    Ms. DeGette. And do you think that mandating the need to 
have an account with the PDMP is the key to Colorado's higher 
provider utilization rates? Is this something you think other 
States should consider?
    Dr. Wolk. Thank you, Representative DeGette. I do. In 
addition to having the allowance for a delegate in the 
prescriber's office, because mandated participation--but then 
actual participation is enhanced by allowing that delegate to 
be assigned----
    Ms. DeGette. Um-hum.
    Dr. Wolk [continuing]. To work on behalf of the provider.
    Ms. DeGette. OK. And I understand also that key medical 
Boards within the State came together, as we do in Colorado 
because that is the way we are, to create prescribing 
guidelines for opioid therapies. Can you talk about how this 
guidance is helping to guide Colorado doctors and dentists in 
their prescribing practices?
    Dr. Wolk. Thank you, Representative DeGette. It is a policy 
that was developed, and then a training from that policy, and 
because of the universal endorsement or adoption by all of 
those different Boards of healthcare professionals that are in 
a position to prescribe, we really have seen a universal 
acceptance, high numbers of participation, and a very high 
number 87 percent, who said they would change their practice 
now as a result of that training.
    Ms. DeGette. So when were all of these guidances, what year 
were they adopted?
    Dr. Wolk. Thank you, Representative DeGette. It is within 
the past 2 years.
    Ms. DeGette. OK, because you had some alarming statistics 
in your testimony about the way opioid use was going up in 
Colorado, and now we seem to be bringing it down. Do you think 
that these new guidelines have helped towards that goal?
    Dr. Wolk. Thank you, Representative DeGette. I do think 
that they have, and we have some preliminary data coming in for 
2014 that shows further stabilization, at least on the 
prescriptive opioids.
    Ms. DeGette. And, Dr. Adams, I wanted to ask you, I 
understand that Indiana has adopted mandatory prescribing 
guidelines for opioid therapies. Can you talk to us about how 
the guidelines work, and what impact that they have had on this 
overprescribing problem?
    Dr. Adams. Well, again, we have seen a 10 percent drop in 
prescribing since we have instituted our opioid prescribing 
rules. And I will tell you, I was on the State Medical 
Association Board of Trustees when these rules were coming 
through. Education is paramount any time you are trying to 
prescribe what doctors are and are not going to do.
    As far as high points, we have an overall threshold in 
terms of if you go over 60 pills per month or 15 milligrams per 
day for over 3 consecutive months, you have to abide by these 
rules. There is a mandatory assessment which includes an H&P, 
and unfortunately we found people were prescribing pills 
without actually seeing patients or doing a full exam.
    Ms. DeGette. Um-hum.
    Dr. Adams. There are regular visits if you are prescribing, 
there is regular checking in with the Prescription Drug 
Monitoring Program, or our INSPECT program, upfront and then at 
regular intervals. There is drug testing, and docs have told us 
over and over and over again we need a way to prove whether or 
not they are taking the drugs or diverting the drugs. So drug 
testing is part of that. There is a daily threshold limit that 
if you go over 60 milligrams per day in the course of therapy, 
then you have to bring the patient back in for a face-to-face 
and consider referring them. And then there are contracts. And 
docs have told us those have been helpful too in terms of 
establishing the relationship, the expectations, and being able 
to fire a patient. The best man at my wedding got sued by 
someone who was using because they said he kicked them out of 
care and abandoned them. Contracts protect doctors moving 
forward in terms of being able to say I told you this, these 
will be the expectations, you violated them, and it empowers 
doctors to be able to participate. But we codified those into 
our rules and regulations, and it has been a tremendous 
success.
    Ms. DeGette. Thank you. I just want to talk for one second 
about treatment because I have heard that there is a shortage 
of doctors who can administer this MAT treatment, particularly 
in rural areas. So I just wanted to ask you, Mr. Stringer, very 
quickly to talk about Missouri. I understand Missouri requires 
all State behavioral organizations to offer MAT treatment to 
all patients with opioid disorders. Has this helped improve 
access for the patients?
    Mr. Stringer. Thank you, ma'am. It absolutely has improved 
access to evidence-based care. I will tell you that this has 
not been easy for our providers to find physicians. We had one 
in southwest Missouri who has since become one of our leading 
providers in medication-assisted treatment, but in the early 
days had to go through the Yellow Pages physician by physician 
to try to find one who was willing, number one, to work with 
this population, because many are not----
    Ms. DeGette. Yes.
    Mr. Stringer [continuing]. And then, secondly, who would 
work for the relatively low reimbursement rates that they could 
offer. So it was a real challenge, but absolutely, it has 
increased access to evidence-based treatment, but we still have 
these waiting lists.
    Ms. DeGette. Thank you. Thank you, Mr. Chairman.
    Mr. Murphy. Thank you.
    Mr. McKinley, recognized for 5 minutes.
    Mr. McKinley. Thank you, Mr. Chairman. Again, thank you for 
continuing this dialogue that we have now been doing for some 
time. We have had four or five hearings this year. Building off 
what we have learned in the past--a couple of years ago, we had 
a hearing in another committee where the Attorneys General had 
come in and talked about one of the things that they were 
suggesting on drug overdose and prescription--the pill mills, 
so to speak, whereas having a national registry in real time 
that was available to people across State lines as a way of 
capturing people that are trying to beat the system, is that 
something--I haven't heard any of you talk about the real-time 
entry data on that. Dr. Wolk, would you--I see you nodding on 
that, is that one of the things we should focus on?
    Dr. Wolk. Thanks, Representative McKinley. Yes, you know, 
we moved from periodic uploading to now daily uploading of the 
information, so it is real time with regard to our Colorado 
PDMP registry.
    Mr. McKinley. Yes, that is just in Colorado, but if they go 
across the State line, that is not available as well.
    Dr. Wolk. Right. I think we would be happy to morph our 
State PDMP into a national PDMP so that--especially for 
neighboring States, I think this is a significant challenge.
    Mr. McKinley. Thank you.
    Dr. Adams, your comment about overprescription--I would 
like to get some more--you started rattling off a lot of 
statistics and things that you do within Indiana to see how 
that works. I would like to see how we might be able to apply 
that in West Virginia as well and maybe across the country. So 
if that is not part of your testimony, if you have that 
separately, if you could send that, because we had this hearing 
just 3 weeks ago. We had seven panelists, and all of them said 
this is the number one priority, this is the number 1--and all 
of them were giving us different priorities. And I would like 
to think that Congress can walk and chew gum at the same time, 
but when we hear from professionals giving us all seven 
different directions, all seven agencies, so we asked them 
twhat is the number-one thing, and they talked about 
prescription.
    Dr. Adams. Um-hum.
    Mr. McKinley. They said we are overprescribing. So in the 
last 3 weeks, I have talked to a number of doctors at 
roundtables in West Virginia, and they are concerned--they 
agree, they say, yes, we are making addicts with what we do, 
but we have to have a development of trust with our patients. 
And do you--I get nervous about the fact that we want Congress 
to try to medicate or try to control--try to practice medicine 
on pain. So they are saying it is trust. How have you been able 
to rectify that or reconcile that in Indiana about dealing with 
that problem?
    Dr. Adams. Well, there is no doubt, and it is obvious from 
our outbreak, that we still have a lot of work to do. And I 
quickly want to touch on the point you brought up earlier. We 
could use a national registry for providers who divert on the 
job. That is the concern. Indiana was also the first State to 
have a Prescription Drug Monitoring Program talk across State 
lines. And it is still a problem. Scott County, Indiana, is 
just 20 minutes north of Louisville, but whether it is a 
national registry or just providing grants and funding to 
facilitate State PDMPs to adopt the best practices that talk 
across State lines, the consistent thing you heard all of us 
say is we need better communication, we need more real time 
information.
    As far as the trust factor, again, it is an uphill climb, 
but we have worked closely with our State medical association, 
and we got buy-in from doctors in terms of participating and 
other prescribers. And I think an important point my 
counterpoint brought up from Massachusetts was that it is not 
just docs, a lot of these are delegated prescribers, and the 
way you get around that problem is you have integration with 
electronic medical records.
    Mr. McKinley. So the more that--if you could get me that 
information----
    Dr. Adams. I would love to.
    Mr. McKinley. Then I want to open it up to all the panel. I 
am just curious, because you raised this issue last time, 3 
weeks ago, and that was that the rate of deaths in America from 
drug overdose is anywhere from 7 to 10 times higher than it is 
in Europe. I raised that question, and I raise it again: What 
are they doing right, or what are we doing wrong? Why from 
30,000 feet--what is the difference, why do we have such a 
problem in America compared to Europe?
    Dr. Adams. Again, pain as the fifth vital sign, and 
overflow of opioids going into the system, a lack of education 
for providers, and understanding on the part of children in the 
States.
    Mr. McKinley. So they are doing a better job in Europe, the 
medical community is doing a better job in Europe?
    Dr. Adams. I think they are. Less opioids available, in 
general, and I will yield to my counterpart from Massachusetts.
    Mr. McKinley. I am sorry, we are going to run out of time. 
So if you could get back to me, please, I would appreciate 
that. Thank you.
    Mr. Murphy. We will appreciate also the further elaboration 
on your point about when that becomes part of the hospital 
satisfaction survey, and then, of course, they get additional 
funding and that cycle, too.
    Now recognize the ranking member, Mr. Pallone, for 5 
minutes.
    Mr. Pallone. Thank you, Mr. Chairman.
    I want to mention, even before the opioid epidemic began, 
our infrastructure for treating substance abuse disorders in 
this country was shamefully inadequate, including cuts to our 
healthcare system through sequestration. A combination of long-
term neglect, social stigma, and underinvestment by both the 
State and Federal Governments has led to a system in which only 
1 in 10 Americans with alcohol or drug addiction receive any 
form of treatment. And of those who receive treatment, only 10 
percent received evidence-based care. You combine this 
neglected behavioral health system with an epidemic of opioid 
overprescribing and it is really not surprising that we are 
currently facing a public health crisis.
    So questions. I would like to ask all the witnesses on the 
panel a question. Is our underinvestment in behavioral health 
services, including the effects of sequestration, hampering our 
response to the opioid epidemic? And let me combine that by 
saying, have you see the effects of sequestration affect what 
you are doing at the State level, and are you able to keep up 
with the increased demand for treatment with the current level 
of resources dedicated to the problem? I guess I will start 
with Dr. Adams and go down.
    Dr. Adams. Thank you for putting me on the spot, 
Representative. One thing that I have always held as my own 
personal adage is spending more is not the same as spending 
wisely. And so we will all come to you all and say we want more 
money, but the fact is what we are concentrating on, and 
something you have heard continually, is that we need to do a 
better job of communicating with each other to make sure we are 
making the most efficient and effective use of the funds that 
we have available. We need to make sure we are talking with 
communities, make sure we are talking with nonprofits, make 
sure that, through electronic medical records, we are getting 
the information that we need.
    Policy is always a pie that gets split up. And so do we 
have enough money, again, I would always love more money, but 
what I would love most from you all is help in terms of making 
sure the right partners are at the table so that we can get the 
most out what we are spending.
    Mr. Pallone. I mean--I appreciate what you are saying, but 
I am saying--my concern obviously is, first, sequestration, but 
even more so, you have more and more people that need 
treatment, and at best we are talking level funding. So, you 
know, if you could be a little more specific about the 
consequences of that, I would appreciate it. Not that I am 
taking away from what you said.
    Dr. Bharel?
    Dr. Bharel. So I want to go back to this point about this 
chronic disease model. So if we look at how we treat other 
diseases within the medical spectrum, when we talk about 
diabetes, there are multiple places to enter based on the level 
of severity. So you come into the emergency room, you go to an 
ICU, you go to a hospital, you go to outpatient. When you are 
suffering with the disease of addiction, there are very few 
routes to enter the system. So when we talk about different 
funding sources, I would like our goal to be to look at it as a 
complete health system.
    Getting back to this concept about Europe. If we think 
about health as a whole entity, and the public health starting 
at the community and going through the hospital system and out, 
we have to culturally think about not in our fast-paced 
thinking about pain being gone, but pain being relieved to a 
certain level, thinking culturally about pain not only being 
relieved with pills but other entities that are available as 
well, and then in addition to that, having PMP. Seventy-nine 
percent of our physicians in Massachusetts are on the PMP, but 
they say when we can't then use painkillers, what are other 
opportunities, so there are educational opportunities there as 
well.
    Mr. Pallone. All right. You guys don't want to--seem to 
want to talk about money.
    Voice. I do.
    Mr. Pallone. Let me add one more thing. Let me add one more 
thing. You know, SAMHSA, we understand that the SAMHSA Block 
Grant, or the Substance Abuse Prevention and Treatment Block 
Grant, you know, has actually been cut by 25 percent in the 
last 10 years. So, you know, maybe we want to talk about that 
if you don't want to talk about the other things. Go ahead.
    Dr. Wolk. Thank you, Representative Pallone. I will be 
quick because I know you want to say something about that.
    Absolutely, sequestration has had an impact. We cannot keep 
up with the demand, number one, so any additional resources 
that we can get through block grant money or however else we 
can do this would really be appreciated because even as a State 
ACA only goes so far with regard to coverages that folks can 
get adequate care. We received $65 million from the Federal 
Government for our innovation model, as Representative DeGette 
alluded to, so that patients coming to their primary care 
doctor can get integrated physical and behavioral healthcare 
services, including substance abuse screening, treatment 
services as well, because we are so desperate to try and 
address this access issue and this lack of resource issue that 
maybe there is something there with regard to where they get 
their primary care.
    Mr. Pallone. Thank you.
    Mr. Stringer. Mr. Chairman, I know we are out of time. If I 
could--I would like to follow up in writing if I can. That is a 
great question. I very much appreciate that. I was at a women's 
prison in Missouri in Vandalia just Tuesday of this week, and I 
have some stories to tell from that experience.
    Mr. Murphy. We would appreciate that. Thank you very much.
    Now recognize Dr. Bucshon for 5 minutes.
    Mr. Bucshon. Thank you, Mr. Chairman.
    And this has been very insightful, your testimony is very 
insightful.
    Dr. Bharel, I was interested in one of the things you said 
that 20 percent of the medication that people are abusing have 
been prescribed for medical reasons, and one of the things we 
have been focusing on, of course, is, you know, I am an 
physician, I was a cardiovascular surgeon before, is 
prescribing, you know, monitoring prescribing habits, but if 80 
percent is coming from somewhere else, where is it coming from? 
Seventy, 80 percent, whatever it is--I think you said 80 
percent.
    Dr. Bharel. Yes, it is 80 percent of what is--70 percent is 
coming from family and friends.
    Mr. Bucshon. OK, that is what I figured, so it is not their 
particular medical use, but at the end of the day, it has been 
prescribed for a medical use for someone. OK, and that is where 
maybe, you know, drop boxes and other initially voluntary 
return policies potentially could be helpful because--last 
year, you probably know, there were enough prescriptions 
written that every person in the United States of America could 
have gotten a bottle of narcotic pain medicine. And Medicare 
Part D just came out and said recently that the number one 
prescribed medicine under Medicare Part D--and so this goes 
across ages, right--was Vicodin.
    Dr. Bharel. Um-hum.
    Mr. Bucshon. And so I am very interested in the prescribing 
programs and trying to monitor, you know, physician 
prescribing, and as part of that, education is, of course, 
important. And that is where it is not only for the people 
using it, but it is the people that are being trained to take 
care of patients as we speak in medical schools and other 
areas. So that is going to be very important.
    Dr. Adams, in your testimony, you say an aggressive 
educational strategy beginning with childhood. Can you kind of 
expand a little bit on that, what your thoughts were on that?
    Dr. Adams. Well, thank you for the opportunity. And for 
those of you who don't know, Congressman Bucshon married up, he 
married an anesthesiologist.
    But as far as that----
    Mr. Bucshon. That is a true statement.
    Dr. Adams. The aggressive education campaign--quick story, 
I was in Scott County just a few weeks ago meeting with a 23-
year-old individual who had HIV, he was in our clinic. And I 
said how did you get started, and he said, ``I had an injury as 
a freshman in high school, a knee injury playing football. The 
doc prescribed me Vicodin. I kind of liked how it made me feel 
so I took all the Vicodin he gave me, took some more, ran 
out.'' He said it was easy to get in the community. ``Got more 
Vicodin. Finally, that wasn't doing the job, switched to 
Oxycontin until that wasn't doing the job, then I started 
injecting.'' And then he switched over to heroin, and now he is 
a 23-year-old HIV addict.
    We have to get to these people earlier. And when you talk 
about an aggressive strategy, it starts with recognition. We 
need an educational campaign to help students understand that 
this is a problem.
    I used to sneak to my friend's house when I was in high 
school and have a beer. They sneak to their friend's house and 
pop a pill. And unfortunately, 1 out of 15 people who divert a 
pill will ultimately go onto heroin use. One out of 15 of my 
friends who popped a beer didn't go on to get HIV. So we need 
to increase the recognition of the problem. We need resilience 
in anti-bullying campaigns so that kids are OK saying no, I am 
not going to take a random pill out of that bowl. We need 
appropriate age level education, and I was meeting with people 
from the State just yesterday who showed us their data, and the 
interventions in each age group are different. What works for a 
fifth grader doesn't work for a sixth grader, doesn't work for 
an eighth grader. There has to be age-appropriate education and 
intervention. There has to be adult and peer outlets so, hey, 
if someone is doing something wrong, I know who to go to, I 
know who to tell. And then finally, to your point, we need 
take-back programs. Sixty-two percent of teenagers who use say 
they--number 1 reason they use is because it is easy to get the 
medication, it is from my parents' cabinet. It is right there. 
It is easier to get a pill than what it was for me to get a 
beer. And you can hide it and you can walk away with it. And so 
all that needs to be part of the campaign, and it needs to 
start in middle school and elementary school.
    Mr. Bucshon. I have one other question I want to ask about 
Naltrexone, because I have given that to patients in a hospital 
setting. And, Mr. Stringer, maybe you can comment on that, and 
I think not only the availability but the appropriate training 
for people, you know, for law enforcement people or EMTs about 
the fact that--like somebody pointed out, it is not a silver 
bullet here, there are also downsides to giving patients Narcan 
or Naltrexone. Can you comment on that, about what type of 
educational stuff is also--I mean--I think, were you one of the 
ones that were commenting on Naltrexone? Yes. Or maybe Dr. 
Bharel could answer that.
    Mr. Stringer. Maybe I can just----
    Mr. Bucshon. Yes.
    Mr. Stringer. I can start. And certainly, I will tell you, 
when I went to----
    Mr. Bucshon. And I am out of time, so can you--why don't we 
just do this----
    Ms. DeGette. Let----
    Mr. Bucshon [continuing]. Why don't you just----
    Ms. DeGette [continuing]. Dr. Bharel answer. She has been--
--
    Mr. Bucshon. Why don't we----
    Mr. Murphy. Why don't we let Dr. Bharel answer?
    Mr. Bucshon. That will be fine.
    Dr. Bharel. So as part of our Narcan Program, so we have 
handed out in Massachusetts since 2007 over 35,000 doses of 
Narcan, and part of that includes to your point about 
education. So the individuals who are handing out the Narcan to 
both bystanders and law enforcement, there is a training that 
goes along with it, and they are also trained on rescue breaths 
and the importance of it being short-acting and to call 911 at 
the same time. And we have recorded over 5,000 reversals----
    Mr. Bucshon. Yes----
    Dr. Bharel [continuing]. With that. So the educational 
component is directly linked when we hand out our----
    Mr. Bucshon. Yes, I think that is important because, in my 
opinion, if someone has to give someone Narcan, they should 
also be calling 911, and those people probably should be 
transported to a medical facility.
    Thank you. I yield back.
    Mr. Murphy. We will want your other thoughts on it, too. We 
have all sorts of people saying that some people have a false 
sense of security thinking, oh, there is Narcan around, I can 
go ahead and take the risk.
    Mr. Tonko, you are recognized for 5 minutes.
    Mr. Tonko. Thank you, Mr. Chair.
    Mr. Stringer, earlier on in the questioning about 
sequestration you had some comments that we didn't get to. 
Perhaps you could share those right now please.
    Mr. Stringer. Yes, thank you very much, Representative. In 
my written testimony, there is a two-page thing from NASADAD 
here that describes the block grant and the reduced purchasing 
power of the block grant over time. I will tell you just 
specifically that I think with regard to sequestration. We in 
the States have really counted on the Federal Block Grant to 
sort of be our--really it is our safety net. We have some 
States have the safety net funds, but the block grant has 
always been stable. It hasn't grown enough to keep pace with 
inflation, but it has been stable. What we saw with the 
sequestration was that our sense of stability was shaken 
because we were during tough economic times at the State level, 
and then our block grant funds were reduced temporarily.
    Just this last Tuesday, I was visiting a women's program in 
Vandalia, Missouri, where we have a unique program going on 
right now where women offenders who leave that institution are 
started on medication-assisted treatment before they leave. So 
when they go home, they return to stable environments. Two of 
the women that I talked to had been on medications before they 
returned to prison. One was a young lady who was young, 
attractive, smart, had two children, was back in prison for her 
fourth DWI offense. Before coming to prison, she had been on 
medication-assisted treatment, but because of budget cuts at 
the State and Federal level, her medication-assisted treatment 
was stopped, and she returned to drinking very quickly after 
that, got her fourth DWI offense and then wound up back in 
prison.
    So, you know, the stability of the block grant, and I hope 
future increases in the block grant, will really help to sure-
up our safety net, and increase access and sustainability of 
treatment.
    Mr. Tonko. I appreciate that. And for far too long our 
national infrastructure for treating substance use disorders 
has suffered from fragmentation, from neglect, and certain 
underinvestment. Only one in ten Americans with substance use 
disorders is able to access treatment, and of the few who 
receive treatment, few receive anything that approximates 
evidence-based care. Reimbursement is key to modernizing these 
services, and ensuring that Americans struggling with addiction 
receive timely, appropriate, and evidence-based care.
    The Affordable Care Act, mental health parity efforts go a 
long way toward accomplishing this, but requiring insurers to 
provide coverage for substance abuse treatment, but much more 
work remains.
    I know the States are experimenting with some innovative 
ideas. Dr. Wolk, can you provide us with an overview of 
Colorado's efforts to integrate behavioral health services into 
the primary care setting in the same Medicaid Program?
    Dr. Wolk. Thank you, Representative Tonko. Yes, and it is 
actually not just for Medicaid, we have a goal that all payers 
in the State will evolve with payment reform models that will 
allow integrated behavioral and medical care to be provided at 
the site of primary care. Our goal over the course of the next 
4 years is that 80 percent of all primary care practices in the 
State, whether they are federally qualified health centers, 
whether they are clinics, whether they are private practices, 
will all have some form of integrated behavioral healthcare as 
part of the primary care that is being provided as the 
patient's medical home.
    Mr. Tonko. And are there any Federal policy changes that 
you would suggest required in order for us to provide--ensure 
integration is indeed successful?
    Dr. Wolk. Thank you, Representative Tonko. There are along 
the lines, again, of really aligning the incentives to make 
sure that payers, for example, don't capitate or apportion 
behavioral health services and payment to a provider that is 
not part of this integrated model. It splits payment and, 
therefore, splits services. And so as a patient, you could come 
see your primary care provider, and that primary care provider 
would be prohibited from providing you mental health or 
substance abuse treatment services because the payer has 
allocated that money to a behavioral healthcare provider or 
substance abuse provider on a prepayment schedule, and that is 
where we could use some help with regard to reforming how those 
payments are made.
    Mr. Tonko. Um-hum. And, Dr. Bharel, just quickly, what do 
you view as the main barrier to integration of behavioral 
health and physical health?
    Dr. Bharel. So I think the main barrier is stigma, and that 
stigma is--penetrates throughout our entire system. My time is 
up so I will stop there. If I can say one more thing is that in 
Massachusetts, we too are looking towards outcome-based, value-
based care throughout our system which includes the real 
cornerstone being primary care and behavioral health 
integration at the office level. We have multiple pilots going 
on including programs of prescribing Suboxone in our community 
health centers. Thank you.
    Mr. Tonko. Thank you.
    I yield back.
    Mr. Murphy. Thank you. Gentleman yields back.
    It is interesting the way deal with stigma straight on, 
integration. Good.
    Mr. Flores, you are recognized for 5 minutes.
    Mr. Flores. My questions have more to do with the education 
elements of that. The background for this is that I have three 
major educational institutions in my district--Baylor, Texas 
A&M University, and University of Texas--that are associated 
with medical schools. And so I would like to drill into going 
further upstream, and that is what can we do with the physician 
community and the expert community, professional community, to 
help them to be able to deal with this better?
    So my first question is this, and this is for each of you. 
Should all physicians be required to complete a continuing 
medical education course on pain treatment, and if so, should 
they also be mandated to complete one on addiction? And I will 
just start with you, Mr. Adams.
    Dr. Adams. Should all physicians? I would change that to 
say all prescribers----
    Mr. Flores. OK.
    Dr. Adams [continuing]. Because it is not just physicians 
prescribing, and not all physicians prescribe opioids. But we 
have had tremendous success, again, in Indiana. Once we 
instituted the opioid prescribing rules, then that led to an 
educational campaign where we had the opportunity and created 
the passion for these docs, and they had to carve out the time 
these docs and other providers to learn about the proper ways 
to prescribe.
    Mr. Flores. OK. Dr. Bharel, your thoughts?
    Dr. Bharel. So we also have all physicians required to do 
pain management training, but to your point, I would say that 
most medical schools, PA schools, nurse practitioner schools, 
et cetera, other practitioners who prescribe, do not have 
acquired training on addiction or its variable in school.
    Mr. Flores. OK.
    Dr. Bharel. So going further upstream at a Federal level, 
these accreditation bodies could be looked at to require some 
of that training.
    Mr. Flores. OK. Dr. Wolk?
    Dr. Wolk. Thank you, Representative Flores. In Colorado, 
some of this training is tied to malpractice premium reduction, 
and so a way around us making a requirement is, you can save 
some money on your malpractice insurance if you take this 
training. And as we said, don't forget about the dentists, the 
nursing community, the optometrists, and the podiatrists 
because they are all prescribers, to the point that was made 
before.
    Mr. Flores. OK. Go ahead, Mr. Stringer.
    Mr. Stringer. And my answer to your question is 
unequivocally yes, there should be mandatory education.
    Mr. Flores. Right. So the next question would be, and this 
is again for all of you: Does your State think there is any 
merit to linking mandatory physician education for PDMPs to DEA 
licensure as a way to promote physician use of PDMPs when 
prescribing a controlled substance? Dr. Adams?
    Dr. Adams. I have been longwinded before so I will be very 
brief. Yes.
    Mr. Flores. OK. Dr. Bharel?
    Dr. Bharel. We already require, at the time of license 
renewal, for all physicians to sign onto PDMP----
    Mr. Flores. I see.
    Dr. Bharel [continuing]. And that is how we have 
increased----
    Mr. Flores. The question is yes on the merit?
    Dr. Bharel. Yes.
    Mr. Flores. OK, great. OK. Perfect.
    Dr. Wolk. Yes, we already require.
    Mr. Flores. OK. Mr. Stringer?
    Mr. Stringer. Sadly, I can only speak theoretically or 
hypothetically since Missouri is the only State in the country 
that does not have a PDMP yet, although it came very close this 
session, but----
    Mr. Flores. OK.
    Mr. Stringer [continuing]. So I would say yes. 
Theoretically, yes.
    Mr. Flores. OK. Theoretically. I understand. Again, for 
each of you, and we have just a minute and 45 left. What are 
the opportunities to--or let me rephrase that. What are the 
opportunities to improve the education of physicians on the 
appropriate prescribing of prescription pain medication? Is it 
medical school, continuing education, all the above, or 
somewhere else?
    Dr. Adams. It is both. I am an assistant professor at the 
medical school, and we don't get it in medical school, but then 
there are docs out there who are prescribing or want to 
prescribe who don't have that education. And I am sorry to keep 
bringing it back, but in many cases, the majority of people 
doing the prescribing of opioids are not physicians. So you can 
do all you want with docs, but if you aren't taking care of 
everyone who is prescribing opioids, you are not going to solve 
the problem.
    Mr. Flores. OK.
    Dr. Bharel. I would say all prescribers at all levels, but 
also to bring back to the point that we all have to be 
educated. So it is a cultural shift also to our expectations of 
pain relief.
    Mr. Flores. OK. Dr. Wolk?
    Dr. Wolk. I believe it is ongoing, but again, think about 
tying it to their wallet and then their malpractice premiums.
    Mr. Flores. Uh-huh, OK. Mr. Stringer?
    Mr. Stringer. All the above.
    Mr. Flores. And the last question is this. And I have just 
a comment. Dr. Bharel, you said something about a cultural 
shift. Is this going to be hard to implement if we began 
pressing all of the prescribers to have continuing education, 
and then further upstream, to have the medical schools or the 
professional schools mandate this as part of their training? Do 
you see pushback in this?
    Dr. Bharel. It is mandated right now in Massachusetts, and 
I believe the prescribers really want to be part of the 
solution, so they are looking to work together. So I think that 
will be the driving force. They are also fed up with the 
numbers and the statistics.
    Mr. Flores. Um-hum.
    Dr. Adams. You will see pushback, but it is something that 
we have to do. And again, as Dr. Bharel mentioned, docs want 
it, but we need to facilitate them getting the education, and 
needing to carve out the time either via tying it to the wallet 
or tying it to certification.
    Mr. Flores. OK, thank you. I yield back the balance of my 
time.
    Mr. Murphy. Gentleman yields back.
    Now recognize the gentlelady from New York, Ms. Clarke, for 
5 minutes.
    Ms. Clarke. I thank you, Mr. Chairman, and I thank our 
ranking member. I also thank our witnesses for lending your 
expertise through your testimony here today.
    I would like to ask about the impact of Medicaid expansion 
on increasing access to treatment for substance abuse 
disorders. According to the Centers for Medicare and Medicaid 
Services, an additional 11.7 million individuals were enrolled 
in Medicaid and CHIP programs since the initial marketplace 
enrollment began in October of 2013, however, 21 States have 
failed to adopt the Medicaid expansion, leaving large coverage 
gaps for adults whose incomes are too high to qualify for 
Medicaid, but too low to qualify for premium tax credits 
through the exchanges.
    Let me start, Dr. Adams, by asking, has Medicaid expansion 
affected access to behavioral health services in the State of 
Indiana?
    Dr. Adams. Well, the answer is yes, but I want to correct a 
term you used. In Indiana, we didn't expand Medicaid, we 
received a waiver to reform our Medicaid program via the 
Medicaid expansion funds. And I think that is a key here that 
we need to allow States to come up with----
    Ms. Clarke. No, I----
    Dr. Adams [continuing]. The best possible policy.
    Ms. Clarke. That wasn't my point.
    Dr. Adams. Yes.
    Ms. Clarke. It was just a question.
    Dr. Adams. Yes, ma'am.
    Ms. Clarke. Has expansion impacted your ability to address 
the HIV outbreak in Scott County?
    Dr. Adams. Expansion via the Healthy Indiana Plan has 
substantially increased our ability. We signed up over 300 
people for health coverage as part of this outbreak into our 
Healthy Indiana Plan.
    Ms. Clarke. Well, I thank you for your illuminating 
response. I hope that other States recognize the impact that 
Medicaid expansion can have on their ability to diagnose and 
treat substance abuse disorders, and comorbidities such as 
mental illness, HIV, and Hepatitis C.
    Mr. Stringer, I would like to turn to you. The current 
limit for nondisabled adults to qualify for Missouri's existing 
Medicaid program, MO HealthNet, is 18 percent of the poverty 
level, or $2,118 a year. Missouri is a State that has not 
expanded Medicaid, resulting in a large coverage gap of adults 
whose incomes are between 18 and 100 percent of the Federal 
poverty level. Mr. Stringer, approximately 300,000 working 
adults would gain access to health coverage through Medicaid 
expansion, is that correct?
    Mr. Stringer. Yes, that is correct.
    Ms. Clarke. How would Medicaid expansion affect the 
population you serve in Missouri?
    Mr. Stringer. Well, ma'am, of those 300,000, we estimate 
that about 50,000 are people with some type of mental illness 
or substance use disorder that have no coverage at all right 
now.
    Ms. Clarke. Um-hum.
    Mr. Stringer. And so we are right now, for those that are 
in our system, we are paying for those with 100 percent general 
funds or block grant funds. If and when we expand Medicaid in 
Missouri, those people will receive Medicaid coverage, which 
does cover substance use disorder treatment in Missouri, and 
that would, therefore, free-up those funds to treat people who 
remain uninsured for whatever reasons, to provide other kinds 
of services to help people get back to work, things like that. 
So it would have a tremendous impact on Missouri.
    Ms. Clarke. Wonderful. I thank you for your perspectives.
    And I yield back the balance of my time. Thank you.
    Mr. Murphy. Gentlelady yields back.
    Now recognize Mrs. Brooks for 5 minutes.
    Mrs. Brooks. Thank you, Mr. Chairman.
    Dr. Adams, you recently wrote an op-ed, and your quote was 
that building a model for prevention and response should this 
type of outbreak happen in other communities in the U.S. Can 
you talk to us a little bit, and kind of trying to bring it 
back a bit to the HIV outbreak in Scott County, can you explain 
for us what the model looks like? When you talk about the 
model, what model are you referring to?
    Dr. Adams. Thank you for the opportunity. And the Governor 
and I sat down at the beginning of this and said we are going 
to make mistakes, but we want this to be a model moving 
forward. And one important part of that was a comprehensive 
program. The HIV spills over into the opioid epidemic, spills 
over into Hepatitis, et cetera. And at our community outreach 
center in Scott County, we wanted to make sure people were able 
to access a multitude of services that are constant barriers to 
them getting into the treatment that they need. At our 
community outreach center, we had over 789 visitors, 271 HIV 
tests, 302 people enrolled in the Healthy Indiana Plan, 87 
mental health referrals, and 38 job referrals. And we also 
offer birth certificates and identification, which is a barrier 
for people signing up for insurance. And importantly, 
immunizations for Hepatitis A, Hepatitis B, and the Tdap. When 
you include the needle exchange into that, I would venture to 
say you won't find another place in our country that offers all 
those services under one small roof.
    Now, what we need to do is look at that as a success, and 
in terms of responding to an epidemic in the future, other 
places should consider providing all those comprehensive 
services, but for the long-term, we need to make sure within 
communities we are not just providing one part, that we are 
providing the comprehensive services people need because, 
again, this is a vulnerable population. OK, here is health 
insurance. Well, I don't have an ID to sign up for it. I can't 
prove I am a citizen. Well, here is access to HIV care. But I 
don't have transportation or it is not available. Well, there 
is an opportunity for you to get into a treatment center. But 
the people aren't here, they are not close by. So when I say a 
comprehensive response and a model response, it is including 
all those services and thinking about overcoming barriers for 
the people we are trying to reach.
    Mrs. Brooks. Thank you very much. And best of luck as you 
continue to lead the efforts on behalf of the State.
    I want to shift very briefly in the time I have left to 
discussion about the criminal justice system. And in a previous 
hearing we talked about drug treatment courts, and obviously 
the State also has a tremendous responsibility for the 
corrections system, and the corrections systems are 
administered by the State. And so I would be interested in any 
of your comments with respect to what your States are doing 
with respect to opioid abuse in our corrections systems, and/or 
the coordination with the drug treatment courts. I know that is 
a big question, but yet I think that is a group of folks who 
are incarcerated or who are on their way to incarceration 
through drug treatment courts, and I am really curious what 
your thoughts have been in your States.
    Dr. Adams. Briefly, in our district, we have had much 
success with Vivitrol and drug courts and diversion programs, 
and we have actually connected the prosecutors from Hamilton 
County, which is in our district, with the people from Scott 
County to share best practices. And I think that is going to be 
a critical, critical aspect moving forward to empowering people 
when they are, quite frankly, a captive audience.
    Mrs. Brooks. Thank you. Dr. Wolk or Mr. Stringer?
    Mr. Stringer. Well, I talked earlier about a project we 
have going on in Missouri within our Department of Corrections 
where people are started on medications before they leave 
prison. That is happening in several of our institutions right 
now, as well as the St. Louis City Jail, before people go into 
drug court. So we are starting people on medications before 
they leave incarceration. We also have a growing number of drug 
courts in Missouri, all of whom have embraced medication-
assisted treatment. In fact, the drug court contracts in 
Missouri require that drug courts offer medication-assisted 
treatment for people for whom it is appropriate.
    Mrs. Brooks. Dr. Wolk, anything with respect to Colorado's 
approach?
    Dr. Wolk. Thank you, Representative Brooks. It varies by 
where the population is most dense. So we have a very active 
program in the Denver metropolitan area. A variety of treatment 
options and transition programs from corrections back into the 
community as well. It is not as easy to take advantage of those 
in the more rural parts of our State.
    Mrs. Brooks. Thank you. Dr. Bharel?
    Dr. Bharel. And in Massachusetts, we have a strong support 
for drug courts, diversion programs, and starting medication-
assisted therapy, and part of our working group includes law 
enforcement and multiple segments of the community. And in 
addition, we have several pilots going on where before release, 
individuals are connected to community health centers so that 
their continuity of care can happen in both behavioral and 
medical illness.
    Mrs. Brooks. Thank you all for your work.
    I yield back.
    Mr. Murphy. Mr. Green, you are recognized for 5 minutes.
    Mr. Green. Thank you, Mr. Chairman.
    I would like to focus question on the overprescribing of 
opioid pain relievers, and what States are doing to prevent the 
opioid addiction in the first place. CDC Director Tom Frieden 
quotes, ``Overdose rates are higher where opioid painkillers 
are prescribed more frequently. States with practices where 
prescribing rates are highest need to take a particularly hard 
look at ways to reduce the inappropriate prescription of these 
dangerous drugs.'' As this quote says, the States where the 
rubber really meets the road in terms of prevention efforts and 
addressing the overprescribing of opioid.
    Dr. Adams, I know Indiana has been hit hard by the opioid 
abuse epidemic. Can you tell us what the mandatory prescription 
guidelines that the Indiana Medical Licensing Board develops, 
and not just the Medical Licensing Board, if you could talk 
about all the practitioners: the nurses and dentists that have 
the same--hopefully their prescribing requirements are on all 
the specialties.
    Dr. Adams. Thank you for the opportunity. And we passed 
those rules and the Medical Licensing Board passed them 
initially for physicians, and now the other Boards are adopting 
their own versions of the rules. But again, a critical part of 
that was the mandatory checking in and being a part of the 
INSPECT, the Prescription Drug Monitoring Program. A mandatory 
part was assessment and H&P and regular visits. You have to 
have a face-to-face and a relationship with a patient before 
you prescribe. A mandatory part of that is drug testing so we 
can know what you are taking, and if you are taking it 
appropriately. And as many people will take more, there are 
frequently people who are diverting.
    Mr. Green. Um-hum.
    Dr. Adams. And we found that problem in Scott County. 
Again, a lot of the prescriptions are to little old ladies who 
really do have chronic pain issues, but they can resell their 
pills for $500, $1,000, and quite frankly, put diapers on their 
grandchildren, versus properly use those opioids. So we need to 
be able to drug test people who we are giving opioids to, and 
we need to have contracts. Again, the docs have told me that 
they are scared to write, and then the docs that are writing 
are scared not to write because you can get sued either way. 
And so we need to be able to protect docs and their ability to 
do the right thing.
    Mr. Green. OK. Do you believe efforts are making an impact 
on inappropriate prescribing of the opioid medications? I know 
you said the other specialties, but at least on the Medical 
Board that you may have some evidence on.
    Dr. Adams. Well, exactly. We have seen drops of 10 percent 
in prescribing since we adopted the rules. We have a lot fewer 
pill mills, and that is really what was the impetus for this, 
but we have to do a better job with our Prescription Drug 
Monitoring Programs. Best practices need to be adopted, and the 
ability to communicate across State lines however we facilitate 
that, because we can't do anything if we don't know the 
numbers, and we can't do anything if we know the numbers but we 
can't share the data with the appropriate prescribers.
    Mr. Green. What should we be doing on the Federal level to 
support your efforts of implementing effective interventions to 
prevent opioid abuse?
    Dr. Adams. Well, Senator Donnelly and Senator Ayotte have a 
bipartisan bill that they are promoting right now that has a 
lot of good ideas in it, and I would encourage you all to look 
at that rather than me spend time going through each of the 
points.
    Mr. Green. Um-hum.
    Dr. Adams. The Heroin and Prescription Opioid Abuse 
Prevention, Education, and Enforcement Act of 2015. I think it 
has a lot of the right ingredients in terms of taskforces and 
highlighting the areas that we need to concentrate on.
    Mr. Green. OK. Dr. Wolk, can you tell us about some of the 
same in Colorado, the opioid prescribing guidelines developed 
by the State Boards, again, whether it is medicine, pharmacy, 
nursing, or dentistry?
    Dr. Wolk. Thank you, Representative Green. Yes, it really 
just keeps coming back from the provider perspective to the two 
main points, or the two number one priorities; one is the 
mandatory participation in PDMP registration, and the second is 
some form of requiring or strongly encouraged training with 
widespread adoption across all the disciplines, because we have 
seen, like I said, 87 percent of those who participate in the 
training said that they would change their practice as a result 
of it.
    Mr. Green. OK. I only have a few seconds. One of the issues 
is doctor-shopping, and is there anything technologically we 
can do to deal with that?
    Dr. Wolk. Yes----
    Mr. Green. And this would be for all of----
    Dr. Wolk. Sure. We have had a lot of success with the use 
of our health information exchange and having broad 
participation by all of our hospital systems in the State of 
Colorado, and now well over 1,000 providers who have connected 
their electronic health records to each other so that when 
somebody comes into an office or an emergency room, it is 
relatively easy to now see who they have seen and what they 
have been prescribed or provided for.
    Mr. Green. Mr. Chairman, in my last second, Dr. Bharel, you 
talked a lot about Federal qualified health centers and the 
community centers. In Massachusetts, do they have access to 
that same medical record across the lines of the different 
centers?
    Dr. Bharel. Yes, sir, there are many different integrated 
health records that we are looking at. And the PMP is really 
adding to this because it is system-wide, any prescription 
written within Massachusetts, or written out of Massachusetts 
for somebody residing in Massachusetts. What we really do need 
though is interoperability that is better between States and 
also between different EHRs, so we can then expand our view.
    Mr. Green. OK, thank you. Thank you, Mr. Chairman.
    Mr. Murphy. Thank you.
    Gentleman from Oklahoma, Mr. Mullin, is recognized for 5 
minutes.
    Mr. Mullin. Thank you, Mr. Chairman, and thank you for 
being persistent on getting down to the roots of the problem. I 
mean this is obviously an epidemic, and I would say most of us 
know somebody that has abused prescription drugs at one time or 
the next. You know, recently I just went through a surgery on 
my elbow and got prescribed a big old pill of pain medicine, 
and I wouldn't even take one of them. Fortunately, I have had a 
lot of surgeries, or unfortunately, and I have built up some 
type of a pain tolerance, but it does become a habit. The pain 
is still there, it just masks it. And when you get used to it, 
it becomes a dependency. And what we are seeing is--in my 
opinion, it is severely being overprescribed. And, Dr. Bharel, 
you are aware of the severe rise in methadone prescriptions, I 
am assuming, right? The rise in it, how often it is being----
    Dr. Bharel. The rise in methadone, yes. Yes.
    Mr. Mullin. Right. Are you aware that methadone accounts 
for 30 percent of overdose deaths, while only----
    Dr. Bharel. Um-hum.
    Mr. Mullin [continuing]. Basically covering 2 percent of 
the prescriptions?
    Dr. Bharel. Yes.
    Mr. Mullin. Then I guess the question is why does 
Massachusetts leave it as a preferred list as a drug to be 
prescribed when CDC is saying it shouldn't be the first line, 
it should be considered just in a case-by-case situation, 
rather than being prescribed on a regular basis?
    Dr. Bharel. Thanks for your question. So methadone, you 
know, has become a part of the armamentarium of what can be 
used as pain relievers. In looking at our data within 
Massachusetts, and the data that we collect at the Department 
of Public Health, when we collect preferred drug of choice 
first and second, methadone is actually lower than the average 
in Massachusetts. It is less than 15 percent as the preferred 
drug of choice. But just like with all the other medications, 
there needs to be education around how to use methadone if it 
is going to be used for pain or not. So I agree with that 
point.
    You brought up a point earlier about many people knowing 
somebody who has used or abused opioids, and I want to bring up 
a point. There was a recent study done through the Harvard 
School of Public Health----
    Mr. Mullin. Um-hum.
    Dr. Bharel [continuing]. Where they looked at the majority 
of us knows somebody who has struggled with addiction, and of 
those who have, 20 percent of us know somebody who has died 
from it. So it is really a profound problem, to your point. And 
one very interesting thing related to this question that you 
are asking is that 36 percent of individuals who were 
prescribed an opiate were not made aware or did not know about 
the addiction potential. So I think that needs to be part of 
the education.
    Mr. Mullin. And I agree with that, but then if we know that 
and it is so readily accessible, still yet I am concerned why 
Massachusetts and Indiana, Dr. Adams, would still leave it on 
your list of prescribed medications, I mean when CDC and 
American Academy of Pain Medicine both have said that methadone 
should not be considered a drug of first choice. But when it is 
listed, we all know that doctors refer to this constantly. In 
fact, that is where Medicaid and Medicare a lot of times gets 
the prescriptions or the drugs that they are able to prescribe 
from.
    Dr. Adams. It is cheap.
    Mr. Mullin. Well, so--I know, but--so a person's life is 
cheap?
    Dr. Adams. Well, no, a person's life is not cheap, and I 
appreciate that question. Again, as a person who has been 
trained in pain management, methadone is a great drug when used 
appropriately.
    Dr. Bharel. Um-hum.
    Dr. Adams. So the problem is that the prescribers aren't 
educated and aren't using it appropriately. So you have a 
policy situation where you have a cheap drug that the doctors 
know can be used appropriately, but a real world situation 
where it is not being used appropriately.
    Mr. Mullin. Dr. Adams, I really appreciate your bluntness, 
but cheap shouldn't matter when we are talking about someone's 
life. We know it is being abused. History says it is being 
abused.
    Dr. Adams. Um-hum.
    Mr. Mullin. So why is it still there?
    Dr. Adams. Well, because, again, from a policy point of 
view, there are two different directions you can take this. You 
can either say take it off the formulary and what are we going 
to replace it with----
    Mr. Mullin. Education isn't working. We all get those 
little bottles with the little label on it, and then it even 
has a folded-up package. And I am sure everybody in this room 
has always read that folded-up package.
    Dr. Adams. Um-hum.
    Mr. Mullin. And all of us know what the side-effects are 
and what the consequences are of everything that we have ever 
taken, and in fact, if you are one of those people, I am not--
--
    Dr. Adams. And as a State health commissioner, I will tell 
you you are right, and again, I will be blunt and say you are 
right. There is a problem and we need to figure out the best 
way to address the problem, while still providing pain 
management options for the people who are out there.
    Mr. Mullin. So, Dr. Adams and Dr. Bharel, while we are 
figuring it out, do you still think it is a good idea to have 
it on your Web site as a preferred medication?
    Dr. Adams. That is a great question, and again, the blunt 
answer is, that is a different division than my division. I 
have spoken with Dr. Werner about this problem, and docs feel 
passionately on both sides of the issue, but it is at the top 
of our radar in terms of making sure we are educating people 
and considering all options.
    Mr. Mullin. Dr. Bharel, you want to follow up on that?
    Mr. Murphy. Gentleman's time has expired. You can do it 
real quickly. We are about to have votes, so I want to move.
    Dr. Bharel. I think this issue is going to be a 
multipronged approach, and one of them is looking carefully at 
the medications we prescribe, and making sure that individuals 
are educated on how to best describe them. Thank you for your 
question.
    Mr. Mullin. Mr. Chairman, thank you.
    Mr. Murphy. Thank you.
    I recognize now Dr. Burgess for 5 minutes.
    Mr. Burgess. Thank you, Mr. Chairman. And I must say, every 
time I listen to the gentleman from Oklahoma, I learn 
something. And it is a hazard in relying on a medical education 
that is over 40 years old, but I remember the morning in 
medical school hearing the lecture on methadone, and it was 
repeated over and over again; methadone is for maintenance 
purposes only. I mean I will never forget the guy saying that. 
But is that no longer true; methadone now is being used for 
things other than maintenance? Dr. Adams.
    Dr. Adams. In terms of maintenance for medication-assisted 
treatment, or you mean for chronic pain?
    Mr. Burgess. Well, for someone who has an opiate 
habituation.
    Dr. Adams. Well, the answer is that there are a lot of 
prescribers out there who don't have the proper education to be 
prescribing the drugs that they are prescribing, and it is a 
problem. It is----
    Mr. Burgess. But again, 40-year-old wisdom, you have 
somebody who has a narcotics habit, they want to rehabilitate 
themselves, they want to get back to taking care of their 
family, back into society, they can be maintained on methadone 
and allowed to function because it didn't have the other 
effects that other opiates do, so they can get the high, but 
they solve the problem of the addiction, at least temporarily. 
But now methadone has uses beyond that?
    Dr. Adams. Well, OK, so I am glad you brought that up. 
Again, there is a lot of misunderstanding about methadone. 
There is methadone as used for chronic pain, which the 
gentleman from Oklahoma was talking about, and then there is 
methadone for medication-assisted treatment, which is the 
person who has substance use disorder who is using it to 
continue functioning. And those are two very different uses of 
methadone, and confusion has led to a lot of policy decisions 
that I think are underinformed. It is important to know that 
methadone can be a substantial and important part of people's 
recovery if they are suffering from substance use disorder, but 
it is also important, to the point of the gentleman from 
Oklahoma, that we recognize and deal with the real problem of 
methadone being prescribed for chronic pain inappropriately, 
because it is killing people. I completely agree with you, and 
I thank you for bringing up that point, sir.
    Mr. Burgess. All right, I am going to switch gears because 
I had a couple of questions about Naloxone. And I have some 
other questions about NASPER, but then I will probably have to 
submit for written responses because of time. But we have had a 
number of these hearings, and I have expressed support for 
having compounds like Naloxone or Narcan available over the 
counter. I mean, let's be honest: People need it, they need it 
right now, they don't need to be going to get a prescription. 
So just this week the FDA announced a public meeting to discuss 
increasing the use of Naloxone. Now, Dr. Bharel, in 
Massachusetts, your State has been kind of an early adopter in 
this area. Can you share some of that experience with us?
    Dr. Bharel. Sure. So as I mentioned earlier, we have been 
using Narcan treatments since 2007. We first started by doing 
outreach to high-risk individuals who were using injection 
drugs as part of an, actually, HIV prevention, treatment 
education program, and since then from there moved on to work 
with so-called bystanders, which hare family and friends. And 
we use our existing community coalitions, such as our learn-to-
cope, family-run coalitions throughout the State in order to 
have them provide Narcan. And this is done through standing 
medical orders, so it is still not an over-the-counter, it is 
through standing medical orders, as well as certain pharmacies 
participate in having it available through standing medical 
orders. And then finally, through the first responders program; 
both fire and police, in dozens of communities across 
Massachusetts have adopted the program as well.
    Mr. Burgess. And, Dr. Adams, can you share with us some of 
your experience in Indiana?
    Dr. Adams. Well, we have had great success, some wonderful 
stories, but I want to second a point that Dr. Bharel made 
earlier that it is important not just to hand out Naloxone, but 
to provide education as part of that process. There is a big 
fear--and I think Representative Murphy brought this up 
earlier, Chairman Murphy--that if you are giving people this, 
they will then use it as an excuse to abuse. That has been 
proven not to be the case when you combine the passing out of 
Naloxone with education. So when you are considering policies 
moving forward, please don't forget the educational component 
because that is what saves lives, along with the Naloxone.
    Mr. Burgess. Yes, of course, that could be said about so 
many other things that we sometimes get involved in, but I 
appreciate your answers.
    Mr. Chairman, I am going to yield back the time because I 
know votes are coming.
    Mr. Murphy. All right, I want to thank all of the members 
who were here for this, and this panel. This has been a 
fascinating process. We know what will come out of this. We 
will get our staffs together. You gave us a great set of 
recommendations today, thank you.
    We do ask you to follow up on some of those other 
questions, and please feel free, if you have other thoughts 
that come from this, it is the kind of things you are thinking 
about on the plane ride back or when you get back to your 
colleagues. We want to see what we need to do in terms of 
drafting legislation, working with the administration on 
regulatory changes, working with associations on some of these 
issues. This is critically important. Too many people have 
died, even during the course of this hearing today. I know you 
all care deeply about this. We share that caring, and we want 
to see this change. So thank you very much.
    So I want to thank all the witnesses and members again for 
being here, and remind members that they have 10 business days 
to submit their questions to record. And we ask that you 
respond promptly to that.
    And with this, this committee hearing is adjourned.
    [Whereupon, at 12:05 p.m., the subcommittee was adjourned.]
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